Managed Care Coordinator II/CM-DM

Spectraforce Technologies; Columbia (SC); Hybrid; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a Managed Care Coordinator II to enhance patient care through effective case management and clinical evaluation. This role involves assessing health needs, coordinating care plans, and ensuring compliance with regulatory standards. Ideal candidates will have a strong clinical background, excellent communication skills, and a passion for patient advocacy. Join a dynamic team dedicated to delivering quality healthcare outcomes and making a meaningful impact in the lives of members. This position offers a supportive environment for professional growth and development, with opportunities for further certification and training.

Qualifications

• 4 years recent clinical experience in defined specialty area.
• Active, unrestricted RN license required.

Responsibilities

• Provides active case management and develops action plans.
• Performs medical review/authorization process for services.
• Participates in patient education regarding healthcare delivery.

Skills

Clinical expertise

Case management

Utilization review

Communication skills

Patient advocacy

Education

Associate Degree in Nursing

Bachelor's degree in Nursing

Master's degree in Social Work

Job description

Role Name: Managed Care Coordinator II/CM-DM

Location: Columbia, SC 29219

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

Schedule: Mon - Fri, 8:30 am to 5:00 pm EST

Contract length: 3 months assignment with possible conversion

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 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.

Day to Day:

• 60%: Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services, and implements plans, including 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.
• 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.).
• 10%: 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).
• 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. 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.

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 Experience: 4 years recent clinical in defined specialty area or 4 years utilization review/case management/clinical experience; 2 of the 4 years must be clinical.

Required License/Certificate: Active, unrestricted RN license from the U.S. and in the state of hire OR active compact multistate unrestricted RN license as per NLC OR active, unrestricted licensure as social worker, counselor, or psychologist from the U.S. and in the state of hire. URAC recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager for Div. 75 and Div. 6B.

Preferred Education: Bachelor's degree in Nursing.

Preferred Work Experience: 7 years healthcare program management.

Preferred Licenses and Certificates: Case Manager certification, clinical certification in specialty area.