Remote Nursing Jobs · Microsoft Office

• Provides active care management and coordinates action plans for members.
• Evaluates outcomes and ensures accurate documentation of clinical information.
• Serves as member advocate and promotes enrollment in care management programs.

BlueCross BlueShield of South Carolina is a leading health insurance company and administrator of government contracts. With an A+ rating and a diverse family of subsidiaries, they are the largest insurer in South Carolina and employ a dedicated team focused on outstanding customer service.

• Perform prospective, concurrent, and retrospective utilization reviews for behavioral health services across multiple care settings.
• Assess medical necessity and coordinate care with providers, members, and internal teams to ensure appropriate access and treatment.
• Support discharge planning, benefit utilization, and regulatory compliance while improving overall care quality.

This company provides high-quality behavioral health coordination and utilization management services to improve member outcomes. They foster a supportive, collaborative environment focused on professional growth and clinical excellence.

• Implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center.
• Functions within the multidisciplinary team to secure complex pre-authorizations and prevent/appeal clinical denials.
• Utilizes clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services provided.

The Ohio State University is a top-20 public university with one of America’s leading academic health centers. They are a team of dedicated colleagues with access to boundless resources.

• Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies.
• Collaborates with client personnel to resolve customer concerns and facilitates resolution of escalated cases.
• Maintains written documentation per HealthHelp’s policy and ensures compliance with HIPAA, state, and federal regulations.

WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With three global headquarters, operations in 13 countries, 65 delivery centers, and more than 66,000 employees, WNS combines scale, expertise, and execution to create meaningful, measurable impact.