Care Management & Authorization Specialist

Hornet Staffing, Inc, a GEE Group company; Columbia (SC); On-site; USD 55,000 - 75,000; Full time

Job summary

Hornet Staffing, Inc., a GEE Group company, seeks a healthcare professional to review medical or behavioral eligibility and apply clinical criteria to service requests. The role plans, coordinates, monitors, and evaluates medical necessity, benefits, and services to support members managing health conditions.

You will document clinical information, collaborate with care management and providers, and ensure compliance with ERISA, NCQA, URAC, and other regulations.

Responsibilities

• Reviews and evaluates medical or behavioral eligibility using clinical criteria to support service requests.
• Assesses medical necessity, options, and services to help members manage health conditions.
• Supports review determinations and ensures appropriate coverage within guidelines.
• Documents clinical information to support medical necessity and coordinates with care management.
• Ensures compliance with ERISA, NCQA, URAC, and other regulatory guidelines.
• Provides discharge planning and assesses service needs with providers and facilities.
• Communicates with health care providers and members regarding requested services.
• Maintains knowledge of contract benefits and assists with claims information and resolution.

Job description

Hornet Staffing, Inc., a GEE Group company, seeks a healthcare professional to review medical or behavioral eligibility and apply clinical criteria to service requests. The role plans, coordinates, monitors, and evaluates medical necessity, benefits, and services to support members managing health conditions.

You will document clinical information, collaborate with care management and providers, and ensure compliance with ERISA, NCQA, URAC, and other regulations.