Coordinator, Managed Care I

Overview Duties: 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 and claims knowledge/analysis to assess, plan, implement, health coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost-effective outcomes. Responsibilities 50%: Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. 20%: Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.). Participates in data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). 10%: Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks, and benefit plans. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. Provides telephonic support for members with chronic conditions, high-risk pregnancy, or other at-risk conditions that consist of: intensive assessment/evaluation of condition, at-risk education based on members' identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement. 10%: Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services. 10%: Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members. Skills & Qualifications Required Skills and Abilities: Required Software and Tools: Microsoft Office. Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Knowledge of contract language and application. Thorough knowledge/understanding of claims/coding analysis/requirements/processes. Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software. Work Environment Typical office environment. Employee may work from one’s/out of one’s home. May involve some travel within one’s community. Work Arrangement Training: Onsite training for the first 1-2 weeks Post-Training: Remote position after training completion Work Schedule: Monday through Friday, 8:30 AM - 5:00 PM Location Requirements Candidates must live within 2 hours of Columbia, SC , a vibrant city known for its rich history, cultural diversity, and friendly community atmosphere. Enjoy the benefits of a bustling city with a small-town feel, offering a great quality of life. Equipment & Technical Requirements Client will provide all required equipment Must have hard-wired internet (no Wi-Fi only setups) Licensing Requirement (Mandatory) Must possess an active, unrestricted RN license Candidates who are not RNs or do not hold the required license will not be considered #J-18808-Ljbffr