Managed Care Coordinator I

Spectraforce Technologies, Inc.; Columbia (SC); Hybrid; USD 60,000 - 80,000; Full time

Job summary

Spectrumforce Technologies, Inc. is hiring a Managed Care Coordinator I in Columbia, SC. This remote-after-training role focuses on reviewing eligibility, coordinating care, and supporting members with health management programs.

Requirements include an RN license, nursing degree, and clinical experience. The position supports discharge planning, care management, and collaboration with providers to ensure appropriate services.

Qualifications

• Active, unrestricted RN licensure in the United States and in the state of hire.
• Associate Degree in Nursing or nursing program graduate.
• 2 years clinical experience.
• Bachelor's degree in Nursing preferred.
• Case Manager Certification or clinical certification preferred.

Responsibilities

• Oversees medical/behavioral reviews to determine coverage within benefits and medical necessity guidelines.
• Coordinates discharge planning and evaluates service needs with providers.
• Communicates with providers and members in writing and by phone.
• Supports care management initiatives and promotes appropriate use of resources.
• Maintains up-to-date knowledge of contracts and network status.

Skills

Clinical review

Discharge planning

Effective communication

Care management knowledge

Data entry / documentation

Education

Associate Degree - Nursing

Bachelor's degree - Nursing (preferred)

Job description

Role Name: Managed Care Coordinator I

Location: Columbia, SC 29229

Work Environment: Remote (after 3-4 days of Onsite training)

Contract length: 3 months assignment with possible conversion

Shift: Mon - Fri, 8:30 AM-5:00 PM

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 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.

Responsibilities

• 50% 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).
• 25% Provides discharge planning and assesses service needs in cooperation with providers and facilities. 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. Collaborates with BCBSSC Care Management and other areas to ensure proper care management processes are executed within a timely manner. Manages assigned members and authorizations through appropriate communication.
• 15% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
• 5% 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. 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.

Required Education

Associate Degree - Nursing, or Graduate of Accredited School of Nursing

Required Experience

2 years clinical experience

Required License/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),

Preferred Education

Bachelor's degree- Nursing Preferred Work Experience: 7 years-healthcare program management.

Preferred Licenses and Certificates

Case Manager Certification, clinical certification in specialty area.

Languages

English