RN - Coordinator, Managed Care I

Join our dynamic team in Columbia, SC, where you'll have the opportunity to make a significant impact in the healthcare industry. As a part of our team, you'll work in a supportive environment that fosters growth and innovation.

Duties

• Review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provide health management program interventions.
• Utilize 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.
• Perform medical or behavioral review / authorization process, ensuring coverage for appropriate services within benefit and medical necessity guidelines.
• Assess service needs, develop and coordinate action plans in cooperation with members, monitor services, and implement plans.
• Evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• Participate in direct intervention / patient education with members and providers regarding healthcare delivery system, utilization on networks, and benefit plans.
• Serve as a member advocate through continued communication and education and promote enrollment in care management programs and / or health and disease management programs.
• Maintain current knowledge of contracts and network status of all service providers and apply appropriately.
• Provide appropriate communications (written, telephone) regarding requested services to both healthcare providers and members.

Skills

Required Skills and Abilities :

Required Software and Tools : Microsoft Office.

Preferred Skills and Abilities :

Preferred Software and Other Tools : Working knowledge of Microsoft Excel, Access or other spreadsheet / database software.

Work Environment

Typical office environment. Employees may work from home. May involve some travel within the Columbia, SC community.