Managed Care Coordinator I

Spectraforce Technologies; Columbia (SC); Remote; USD 50,000 - 80,000; Full time

Job summary

An established industry player is seeking a dedicated clinical professional to join their team. This role involves evaluating medical eligibility and providing health management interventions to support members in managing their health. You will work closely with a tight-knit group, utilizing your clinical expertise to ensure quality and cost-effective outcomes. The position offers a unique opportunity to impact patient care positively while working remotely after initial training. If you are passionate about healthcare and have the required clinical experience, this position could be the perfect fit for you.

Qualifications

• 2 years clinical experience required.
• Active RN or LMSW licensure is necessary.

Responsibilities

• Conduct medical or behavioral reviews and authorizations.
• Provide telephonic support for members with chronic conditions.
• Participate in data collection for clinical information flow.

Skills

Clinical expertise

Health coaching

Claims knowledge

Patient education

Motivational interviewing techniques

Education

Associate Degree - Nursing

Master's degree in Social Work

Bachelor's degree - Nursing

Job description

Work Environment : (Remote after 1 week of Onsite training)

Schedule : Mon to Fri, 8 : 30 am - 5pm

Contract length : 3 months assignment with possible conversion

Job Summary :

Duties / About the role :

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.

Day to Day :

• 50% 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.
• 20% 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. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and / or health and disease management programs.
• 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.
• 10% 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.
• 10% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

Team Info : We are a very tight knit group that has been together for a while.

Job Requirements :

Required Education : Associate Degree - Nursing or Graduate of Accredited School of Nursing or Master's degree in Social Work, Psychology, or Counseling.

Required Work Experience : 2 years clinical experience.

Required License and Certificate : Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LMSW (Licensed Master of Social Work) licensure from the United States and in the state of hire, OR active, unrestricted licensure as Counselor, or Psychologist from the United States and in the state of hire.

Preferred Education : Bachelor's degree- Nursing.

Preferred Work Experience : 7 years-healthcare program management, utilization review, or clinical experience in defined specialty. Specialty areas are oncology, cardiology, neonatology, maternity, rehabilitation services, mental health / chemical dependency, orthopedic, general medicine / surgery.