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Managed Care Coordinator I

Spectraforce Technologies
United States, South Carolina, Columbia
May 14, 2025
Role Name: Managed Care Coordinator I Location: Columbia, SC 29229 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: Duties/About the role: 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 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. Utilizes available resources to promote quality, cost effective outcomes. Day to Day: 50% Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. 20% 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). 10% Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. Provides telephonic support for members with chronic conditions, high risk pregnancy or other at risk conditions that consist of: intensive assessment/evaluation of condition, at risk education based on members' identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement. 10% 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. 10% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members. Team Info:* We are a very tight knit group that has been together for a while. We precert outpatient procedures that are done both in office and in the hospital. We work with the concurrent nurses as well as case management. We also work very closely with our medical directors * We have direct contact with provider and members as well. Any extra/additional job info: NA 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: Associate Degree - Nursing, OR, Graduate of Accredited School of Nursing, OR, Master's degree in Social Work (for Div. 6B or Div. 75) or Master's in Psychology, or Counseling (for Div. 75 only). Required Experience: 2 years clinical experience Required License/Certificate: An active, unrestricted RN license 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) OR, active, unrestricted licensure as social worker from the United States and in the state of hire (in Div. 6B) OR, active, unrestricted licensure as counselor, or psychologist from the United States and in the state of hire (in Div. 75 only). For Div. 75 and Div. 6B, except for CC 426: URAC recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager. 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.