Coordinator, Managed Care II/CM-DM

TALENT Software Services; Columbia (SC); Hybrid; USD 65,000 - 90,000; Full time

Job summary

TALENT Software Services in Columbia, SC, is seeking a licensed RN to join our patient-focused care management team. The role involves evaluating medical and behavioral eligibility, coordinating services, and supporting members with chronic or acute conditions in a hybrid work setting.

Responsibilities include active case management, reviews for medical necessity, and member education. Strong MS Office skills and experience in high-risk populations are preferred; SC license required.

Qualifications

• SC RN license required.
• Must live in South Carolina.
• Experience in critical care, ICU, ER, or Step-down units preferred.
• Contract to hire; remote/hybrid work arrangement.

Responsibilities

• Reviews and evaluates medical/behavioral eligibility for benefits and clinical criteria.
• Provides active case management, coordinates action plans with members, and monitors services.
• Performs medical/behavioral review and ensures coverage within guidelines.
• Provides patient education and health care delivery system guidance; maintains documentation.

Skills

RN supervision

Client communication

Analytical thinking

MS Office proficiency

Healthcare claims analysis

Education

SC RN license

Tools

Microsoft Office

Excel

Outlook

Teams

Access

Job description

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, 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 thatconsist 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 isnot 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. null

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. null

Schedule Notes

MAX PAY RATE - ***/HR

NON SCA

CONTRACT TO HIRE- Not a long-term contract role.

APPLICANTS MUST HAVE ANY OF THE FOLLOWING EXPERIENCE TO BE CONSIDERED FOR THE POSITION, CRITICAL CARE EXPERIENCE, ICU, ER, cardiac PACU, Progressive care unit or Step-down units

Remote/Hybrid (depends on the pace of the employee and validation of competency)

• Training Onsite (Travel is covered/Reimbursed by Client) Should expect to be in office for orientation for at least 4 weeks.

MUST LIVE IN SOUTH CAROLINA, must have a valid South Carolina RN license

• Hours/Schedule: 8AM-430PM M-F and Call every 4-6 weeks once fully trained-Call will not begin for at least 3 months. Call hours are less than 6 hours per weekend assigned, there are exceptions to this and will be reviewed with Management
• Teams Interview with Program Manager
• Times for interview dates:

• Mondays 9-1:30
• Tuesdays 9-11:30,
• Wednesdays 10—4
• Thursday 9-12, 2-4
• Fridays 9-12, 2-4
• Must be an RN, live in SC and have an active SC nursing license.
• Appeals and reconsideration experience preferred
• Utilization management experience preferred
• Prior experience working for a health insurance company and/or with Medicare population
• Flexibility, dependability- we are often called to assist other depts.
• Strong analytical stills, each case is a puzzle that needs to be put together, not an a,b,c checklist.
• Knowledge of MS Office (Outlook, Teams, Excel) and able to learn and work out of multiple systems simultaneously.
• Ability to work independently
• Self-driven to accomplish a productivity goal without constant direction
• Hours 7 days a week, weekends and holidays are on-call hours.