Managed Care Specialist

Hornet Staffing, Inc, a GEE Group company; Columbia (SC); On-site; USD 55,000 - 75,000; Full time

Job summary

Hornet Staffing, Inc., a GEE Group company, seeks a healthcare professional to review medical or behavioral eligibility and apply clinical criteria to service requests. The role plans, coordinates, monitors, and evaluates medical necessity, benefits, and services to support members managing health conditions.

You will document clinical information, collaborate with care management and providers, and ensure compliance with ERISA, NCQA, URAC, and other regulations.

Responsibilities

• Reviews and evaluates medical or behavioral eligibility using clinical criteria to support service requests.
• Assesses medical necessity, options, and services to help members manage health conditions.
• Supports review determinations and ensures appropriate coverage within guidelines.
• Documents clinical information to support medical necessity and coordinates with care management.
• Ensures compliance with ERISA, NCQA, URAC, and other regulatory guidelines.
• Provides discharge planning and assesses service needs with providers and facilities.
• Communicates with health care providers and members regarding requested services.
• Maintains knowledge of contract benefits and assists with claims information and resolution.

Job description

• 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. 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 Client 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.