RN/Managed Care Coordinator (Remote

Job Description

Job Description

Must live in the state of South Carolina and be willing to work the first 1-2 weeks onsite in Columbia.
Must have an active, unrestricted RN license in the state of South Carolina
Monday-Friday 830-5
Pay - 30/hr

• 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.
• 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.