Coordinator, Managed Care II/CM-DM

Job Summary : Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions. Utilizes clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of the healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members managing chronic or acute conditions. Key Responsibilities 60% - Case Management (Primary) Active case management of assigned members Develops and coordinates care plans Monitors services and evaluates outcomes Assesses: Eligibility, Level of benefits, Place of service, Length of stay & Medical necessity Provides telephonic support for: Chronic conditions & High-risk members Conducts: Member assessments, Patient education, Motivational interviewing & Behavior change coaching 20% - Utilization Management / Authorization Performs medical/behavioral review Handles prior authorization and coverage decisions Supports determinations with clinical documentation Refers cases to: Medical Director, Case Managers, Quality teams Ensures compliance with: ERISA, NCQA, URAC, DOI & DOL 10% - Member Advocacy Educates members/providers Promotes care management programs Supports healthcare navigation 5% - Administrative Maintains provider contract knowledge & assists with claims resolution 5% - Communication Written + telephonic communication with providers & members Required Skills Strong analytical thinking ("each case is a puzzle") Independent decision-making Strong communication skills Ability to manage productivity targets Microsoft Office (Outlook, Teams, Excel) Multi-system navigation Education & Experience Associate Degree in Nursing OR equivalent OR 4 years clinical experience OR 4 years UM / Case Management / Clinical (2 years clinical mandatory) Licensure Active RN license (SC required) Preferred Appeals / reconsideration experience Utilization management experience Health insurance / Medicare experience Case management certification #J-18808-Ljbffr TALENT Software Services