RN​/Case Management Coordinator - Remote

Job Description Registered Nurse (RN) Care Management Specialist

Location: Remote
- Onsite for Training (Must reside within 2 hours of Columbia, SC)

Pay Rate: $30/hour

• Monday through Friday, 8:30 AM - 5:00 PM
• Two late shifts per month: 11:30 AM - 8:00 PM
• No late shifts on Fridays
• Required onsite training in Columbia, SC during the first week

• Active, unrestricted Registered Nurse (RN) license in South Carolina
• Minimum of 4 years of recent clinical nursing experience
• Must live within 2 hours of Columbia, South Carolina
• Ability to attend onsite training in Columbia during the first week of employment

We are seeking an experienced Registered Nurse (RN) to support members through clinical review, care management, and health advocacy services. This role is responsible for evaluating medical and behavioral health requests, coordinating care, promoting quality outcomes, and ensuring services meet clinical and benefit eligibility requirements.

• Review and evaluate medical and behavioral health requests for eligibility, benefits, and medical necessity using established clinical guidelines and policies.
• Assess, plan, coordinate, monitor, and evaluate care for members with chronic, acute, or complex health conditions.
• Provide active case management, including assessing service needs, developing care plans, coordinating services, and monitoring progress toward member goals.
• Determine appropriate levels of care, benefits eligibility, length of stay, place of service, and medical necessity for requested services.
• Maintain accurate and thorough clinical documentation to support medical necessity and benefit determinations.
• Deliver telephonic care management and health coaching for members with chronic conditions, high-risk pregnancies, and other at-risk health concerns.
• Utilize motivational interviewing, reflective listening, and behavior-change strategies to improve member engagement and health outcomes.
• Conduct utilization review and authorization activities to ensure services align with benefit plans and medical necessity criteria.
• Collaborate with internal teams and refer cases as appropriate to Medical Directors, Case Managers, Preventive Services, Quality Management, and other specialty departments.
• Support clinical data collection and documentation processes to ensure accurate claims adjudication and reporting.
• Promote quality, cost-effective healthcare solutions while advocating for members' healthcare needs.
• Ensure compliance with all applicable regulatory and accreditation standards, including ERISA, NCQA, URAC, Department of Insurance (DOI), and Department of Labor (DOL) requirements.