Coordinator, Managed Care II/CM-DM

TALENT Software Services; Columbia (SC); Vor Ort; USD 60.000 - 80.000; Vollzeit

Zusammenfassung

A healthcare management firm located in South Carolina seeks a qualified professional for a role focused on case management and utilization review. The position involves active management of healthcare cases, development of care plans, member assessments, and telephonic support. Candidates must have an Associate Degree in Nursing or equivalent, an active RN license, and strong analytical and communication skills. This role offers opportunities to work with members managing chronic or acute healthcare conditions.

Qualifikationen

• Associate Degree in Nursing OR equivalent OR 4 years clinical experience OR 4 years UM / Case Management / Clinical (2 years clinical mandatory).
• Active RN license (SC required).

Aufgaben

• Active case management of assigned members.
• Develops and coordinates care plans.
• Monitors services and evaluates outcomes.
• Assesses eligibility and medical necessity.
• Educates members and promotes care management programs.

Kenntnisse

Analytical thinking

Independent decision-making

Communication skills

Productivity management

Microsoft Office (Outlook, Teams, Excel)

Multi-system navigation

Ausbildung

Associate Degree in Nursing or equivalent

Jobbeschreibung

Job Summary: 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 the healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members managing chronic or acute conditions.

Key Responsibilities

60% - Case Management (Primary)

• Active case management of assigned members
• Develops and coordinates care plans
• Monitors services and evaluates outcomes
• Assesses: Eligibility, Level of benefits, Place of service, Length of stay & Medical necessity
• Provides telephonic support for: Chronic conditions & High-risk members
• Conducts: Member assessments, Patient education, Motivational interviewing & Behavior change coaching

20% - Utilization Management / Authorization

• Performs medical/behavioral review
• Handles prior authorization and coverage decisions
• Supports determinations with clinical documentation
• Refers cases to: Medical Director, Case Managers, Quality teams
• Ensures compliance with: ERISA, NCQA, URAC, DOI & DOL

10% - Member Advocacy

• Educates members/providers
• Promotes care management programs
• Supports healthcare navigation

5% - Administrative

Maintains provider contract knowledge & assists with claims resolution

5% - Communication

Written + telephonic communication with providers & members

Required Skills

• Strong analytical thinking ("each case is a puzzle")
• Independent decision-making
• Strong communication skills
• Ability to manage productivity targets
• Microsoft Office (Outlook, Teams, Excel)
• Multi-system navigation

Education & Experience

• Associate Degree in Nursing OR equivalent OR 4 years clinical experience OR 4 years UM / Case Management / Clinical (2 years clinical mandatory)

Licensure

• Active RN license (SC required)

Preferred

• Appeals / reconsideration experience
• Utilization management experience
• Health insurance / Medicare experience
• Case management certification