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