RN / Medical Reviewer / Remote
InGenesis is currently seeking a Registered Nurse / RN - Managed Care Coordinator to work for our client located in Columbia, SC. In this role you will review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria and assess and monitor medical necessity using your clinical proficiency and claims knowledge. This is a REMOTE opportunity for candidates living in the state of South Carolina! Apply today and we’ll reach out to answer any questions you may have. Job Duties
- Perform medical review/authorization process.
- Ensure coverage for appropriate services within benefit and medical necessity guidelines.
- Assess service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans.
- Evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay and medical necessity regarding requested services and benefit.
- Ensure accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
- Utilize allocated resources to back up review determinations.
- Identify and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.).
- Participate in data collection/input into system for clinical information flow and proper claims adjudication
- Perform other duties as assigned.
Minimum Qualifications
- Current Registered Nurse / RN license in the State of South Carolina.
- Associates degree in nursing or graduate from accredited nursing school.
- 4 years of clinical experience in specialty areas like: oncology, cardiology, neonatology, maternity, rehab, mental health/chemical dependency or surgery. OR
- 4 years of utilization review/case management or combination of clinical experience.
EEO Statement InGenesis is an equal opportunity employer committed to fostering a diverse, inclusive, and equitable workplace. We comply with all applicable federal, state, and local employment laws, including recent executive orders, and strictly prohibit discrimination, harassment, or retaliation based on race, color, religion, sex, sexual orientation, gender identity, national origin, disability, genetic information, age, veteran status, or any other characteristic protected by law. InGenesis is dedicated to making reasonable accommodations for qualified individuals with disabilities and ensuring that all employment decisions are based on qualifications, merit, and business needs. If you require a reasonable accommodation during the hiring process, please contact us by visiting our website at https://www.ingenesis.com/careers/site-accommodations. To learn more about your rights, please refer to the Know Your Rights: Workplace Discrimination is Illegal poster issued by the U.S. Equal Employment Opportunity Commission (EEOC). Company Statement With decades of experience, InGenesis has grown into one of North America’s most trusted Healthcare Services Firms, which includes comprehensive health and workforce solutions. As the industry landscape shifts with new challenges in patient care, quality and compliance requirements, workforce retention, and operational efficiencies, we deliver strategic, data-driven solutions that include redefining workforce management and clinical service delivery. Explore InGenesis to discover how our expertise, innovative strategies, and commitment to excellence are shaping the future of healthcare workforce solutions. Join us in celebrating the professionals who define the next era of healthcare.apply to this job