Registered Nurse (RN) - Utilization Management / Case Management (Medicare)

Are you an experienced Registered Nurse (RN) - Utilization Management / Case Management (Medicare) with a desire to excel? If so, then Talent Software Services may have the job for you! Our client is seeking an experienced Registered Nurse (RN) - Utilization Management / Case Management (Medicare) to work at their company in Columbia, SC.

Overview: We are hiring for Registered Nurses across multiple Managed Care functions, including Utilization Management (UM) and Case Management (CM/DM), supporting Medicare populations. These roles involve a mix of clinical review, prior authorizations, appeals, and member care coordination in a fast-paced, performance-driven environment.

Key Responsibilities:

• Review medical necessity and process prior authorization requests
• Perform utilization review and/or appeals handling
• Manage member cases, including care planning and coordination
• Support Medicare population with chronic or acute conditions
• Conduct telephonic case management and patient education
• Collaborate with providers, care teams, and internal departments
• Ensure compliance with clinical guidelines and regulatory standards
• Maintain accurate and detailed clinical documentation

Qualifications:

• Active RN license (South Carolina or compact)
• 4+ years of recent clinical experience OR utilization management OR case management experience
• Experience with Medicare or Managed Care environments
• Strong clinical judgment and analytical skills
• Excellent written and verbal communication

Preferred:

• Prior Authorization and/or Appeals experience
• Case Management / Disease Management background
• Behavioral Health or Adult Care experience
• Experience working with health insurance providers

Work Model & Training

• On-site training required (1-6 weeks depending on role)
• Remote/hybrid flexibility available post-training based on performance
• Must be located in South Carolina (or within 2 hours of Columbia, SC)

Compensation & Engagement

• Contract and Contract-to-Hire opportunities available
• Equipment provided for remote work

Important Considerations

• Local candidates only (South Carolina)
• Stable work history required
• Must have a secure home workspace and reliable high-speed internet