Managed Care Coordinator UM II

Spectraforce Technologies; Columbia (SC); Hybrid; USD 28,000 - 55,000; Part time

Job summary

Spectraforce Technologies is seeking a part-time Managed Care Coordinator UM II in Columbia, SC. The role involves reviewing medical and behavioral eligibility, applying clinical criteria, and coordinating care to support members with health management needs.

The position requires an RN license, clinical utilization review or case management experience, and strong communication skills. Onsite training is provided, with remote work possible after four weeks of on-site training.

Qualifications

• Active RN license in the United States and state of hire.
• Experience in utilization review and case management.
• Ability to assess medical necessity and coordinate care.

Responsibilities

• Review medical/behavioral eligibility and authorize services per guidelines.
• Coordinate discharge planning with providers and facilities.
• Communicate with members and providers regarding services and plans.
• Provide patient education on care options and health management.
• Maintain knowledge of contracts, networks, and authorization processes.

Skills

RN licensure

Clinical review

Care coordination

Education

Associate Degree - Nursing

Bachelor's degree - Nursing

Job description

Role Name: Managed Care Coordinator UM II (Part-time)

Location: Columbia, SC 29203

Work Environment: Remote (after 4 weeks of Onsite training)

Contract length: 3 months assignment with possible conversion

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

4 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery. OR, 4 years utilization review/case management/clinical/or combination; 2 of 4 years must be clinical.

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