Case Management Coordinator

Hornet Staffing, Inc, a GEE Group company; Columbia (SC); On-site; USD 65,000 - 90,000; Full time

Job summary

Hornet Staffing, Inc, a GEE Group company, seeks a skilled case management professional to review medical/behavioral eligibility and coordinate care for members. The role involves active case management, planning, and monitoring outcomes to ensure medical necessity and optimal services while promoting cost-effective care.

The candidate will provide telephonic support, educate members, and collaborate with providers to coordinate services, ensuring compliance with regulatory guidelines and

Qualifications

• Experience with word processing software and basic data management.
• Knowledge of quality improvement processes and related activities.
• Ability to work independently, prioritize effectively, and make sound decisions.

Responsibilities

• Review and evaluate medical or behavioral eligibility for benefits and program interventions.
• Provide active case management, assess service needs, develop action plans, and monitor services.
• Conduct telephonic support for members with chronic conditions or high-risk needs; educate and coach members.

Skills

MS Office proficiency

Analytical thinking

Communication skills

Customer service

Tools

Microsoft Office

Job description

Review and Tasks:

• 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 healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, 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.
• 60% Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. 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.
• 20% Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. 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. May identify, initiate, and participate in on-site reviews. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs.
• 5% 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.
• 5% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

Skills:

Required Skills and Abilities:

• Working knowledge of word processing software. Knowledge of quality improvement processes and demonstrated ability with these activities. Knowledge of contract language and application. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.
• Required Software and Tools: Microsoft Office.
• Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and 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 form one's/out of one's home. May involve some travel within one's community.