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.
- Current Registered Nurse / RN license in the State of South Carolina.
- Associates degree in nursing or graduate from accredited nursing school.
- 2+ years of clinical experience.