Managed Care Coordinator I

4 weeks ago

Columbia, United States Spectraforce Technologies Full time
Job Title: Managed Care Coordinator I
Location: Columbia, SC. 29229 (Remote, after onsite training)
Duration: 3 months assignment with possible temp to hire
Shift: Mon-Fri, 8:30 am - 5 pm
Pay rate: $30/hr.

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 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.

Responsibilities:
  • 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.
Required Education: Associate Degree - Nursing or Graduate of Accredited School of Nursing or Master's degree in Social Work, Psychology, or Counseling.
Required Work Experience: 2 years clinical experience.
Required License and 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), OR, active, unrestricted LMSW (Licensed Master of Social Work) licensure from the United States and in the state of hire, OR active, unrestricted licensure as Counselor, or Psychologist from the United States and in the state of hire.

Preferred Education: Bachelor's degree- Nursing.
Preferred Work Experience: 7 years-healthcare program management, utilization review, or clinical experience in defined specialty. Specialty areas are oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery.
Languages: English.

  • Managed Care Coordinator

    1 day ago

    Columbia, United States Mindlance Full time

    Job Title: Managed Care Coordinator Job Location: Columbia, SC Top 3/5 Skills: RN / Registered Nurse License Chronic condition care Case Management Job Responsibilities Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established...

  • Managed Care Coordinator

    4 days ago

    Columbia, United States Mindlance Full time

    Job Title: Managed Care Coordinator Job Location: Columbia, SC Top 3/5 Skills: · RN / Registered Nurse License · Chronic condition care · Case Management Job Responsibilities Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical...

  • In Home Care Coordinator

    7 days ago

    Columbia, United States Phoenix Home Care and Hospice Full time

    Job DescriptionJob DescriptionPhoenix Home Care and Hospice is a leading provider of home care services in the Hospital & Health Care industry. We are currently seeking a motivated and compassionate In Home Care Coordinator to join our dedicated team. As an In Home Care Coordinator, you will play a key role in ensuring the delivery of high-quality care to...

  • Quality Coordinator I

    2 days ago

    Columbia, United States FLASH Technology Group Full time

    The Quality/Ticket Coordinator I, as part of a 24x7 Service Desk, perform the activities associated with the management of dedicated ticket queues to include prioritization of work and assignment to technical resources for resolution of end user concerns while ensuring service levels and objectives are met. Responsibilities include: -Monitoring dedicated...

  • In Home Care Coordinator

    1 week ago

    Columbia, Missouri, United States Phoenix Home Care and Hospice Full time

    Phoenix Home Care and Hospice is a leading provider of home care services in the Hospital & Health Care industry. We are currently seeking a motivated and compassionate In Home Care Coordinator to join our dedicated team. As an In Home Care Coordinator, you will play a key role in ensuring the delivery of high-quality care to our clients while upholding our...

  • Managed Care Coordinator

    19 hours ago

    West Columbia, United States Mindlance Full time

    Job Title: Managed Care Coordinator Job Location: Columbia, SC Top 3/5 Skills: · RN / Registered Nurse License · Chronic condition care · Case Management Job Responsibilities Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and...

  • Private Duty Care Coordinator

    1 month ago

    Columbia, United States Phoenix Home Care and Hospice Full time

    Job DescriptionJob DescriptionPhoenix Home Care and Hospice in Columbia, MO is looking for a Private Duty Care Coordinator!Are you a team player with a heart for people? Are you cool under pressure? Are you organized and fun to work with even in a fast paced environment? Then Phoenix Home Care and Hospice might want to hear from you! This position offers the...

  • Clinical Donation Coordinator I

    2 weeks ago

    West Columbia, United States Sharing Hope SC Inc Full time

    Clinical Donation Coordinator I Job Details Job Location Columbia - West Columbia, SC Description Summary The Clinical Donation Coordinator (CDC I) responds to referrals of potential organ donors and is responsible for evaluating and setting the plan for medical management for optimal organ function to obtain and assure effective organ donation. Essential...

  • Quality Coordinator I with Security Clearance

    2 days ago

    Columbia, United States Flash Technology Group LLC Full time

    The Quality/Ticket Coordinator I, as part of a 24x7 Service Desk, perform the activities associated with the management of dedicated ticket queues to include prioritization of work and assignment to technical resources for resolution of end user concerns while ensuring service levels and objectives are met. Responsibilities include: -Monitoring dedicated...

  • Account Manager I

    1 day ago

    Columbia, United States Computershare Full time

    Spends the majority of working time performing independent work as part of a team. Uses existing processes and procedures to solve routine or standard problems. May act as a lead on small projects, coordinating and faci **ocation: Columbia, MD (Hybrid)** This is a hybrid position primarily based in Columbia, MD. We’re committed to your flexibility and...

  • Private Duty Care Coordinator

    1 month ago

    Columbia, Missouri, United States Phoenix Home Care and Hospice Full time

    Phoenix Home Care and Hospice in Columbia, MO is looking for a Private Duty Care Coordinator! Are you a team player with a heart for people? Are you cool under pressure? Are you organized and fun to work with even in a fast paced environment? Then Phoenix Home Care and Hospice might want to hear from you! This position offers the right candidate a...

  • Clinical Donation Coordinator I

    2 weeks ago

    West Columbia, United States We Are Sharing Hope SC Full time

    Job DetailsJob Location Columbia - West Columbia, SC DescriptionSummary The Clinical Donation Coordinator (CDC I) responds to referrals of potential organ donors and is responsible for evaluating and setting the plan for medical management for optimal organ function to obtain and assure effective organ donation. Essential Duties & Responsibilities ...

  • Clinical Donation Coordinator I

    3 weeks ago

    West Columbia, United States WE ARE SHARING HOPE SC Full time

    Job DetailsJob LocationColumbia - West Columbia, SCDescriptionSummaryThe Clinical Donation Coordinator (CDC I) responds to referrals of potential organ donors and is responsible for evaluating and setting the plan for medical management for optimal organ function to obtain and assure effective organ donation.Essential Duties & ResponsibilitiesResponsible for...

  • Accountant I

    1 month ago

    Columbia, United States SC Student Loan Full time

    Job DescriptionJob DescriptionThe Accountant I is responsible for performing administrative financial functions in the Financial Services department. This position will report to the Vice President of Finance with minimal supervision. This position will apply accounting principles and practices to a range of accounting, budgeting, and other fiscal functions....

  • Coordinator, Managed Care II/CM-DM

    1 week ago

    Columbia, United States LanceSoft Full time

    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...

  • Coordinator, Managed Care II/CM-DM

    1 day ago

    Columbia, United States Mindlance Full time

    Duties: 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...

  • Care Coordinator, System of Care Across TN

    2 weeks ago

    Columbia, United States Mental Health Cooperative Full time

    Ranked one of Tennessee’s top places to work, MHC is a rare and special place where outstanding company culture is intentional. Where clients and associates are treated the same, as equals.Mental Health Cooperative, Inc. (MHC) was formed in 1993 to serve individuals with severe and persistent mental illness. Since then, we have expanded our services to...

  • Care Coordinator, System of Care Across TN

    1 week ago

    Columbia, United States Mental Health Cooperative Full time

    Ranked one of Tennessee’s top places to work, MHC is a rare and special place where outstanding company culture is intentional. Where clients and associates are treated the same, as equals. Mental Health Cooperative, Inc. (MHC) was formed in 1993 to serve individuals with severe and persistent mental illness. Since then, we have expanded our services to...

  • Care Coordinator, System of Care Across TN

    2 weeks ago

    Columbia, United States Mental Health Cooperative Full time

    Ranked one of Tennessee’s top places to work, MHC is a rare and special place where outstanding company culture is intentional. Where clients and associates are treated the same, as equals.Mental Health Cooperative, Inc. (MHC) was formed in 1993 to serve individuals with severe and persistent mental illness. Since then, we have expanded our services to...

  • Patient Care Coordinator

    1 month ago

    Columbia, United States Gastro Center of Maryland Full time

    Gastro Center of Maryland has an opening for a Full-Time Patient Care Coordinator. Must have experience in a fast-paced medical environment. Must have exceptional customer service skills, excellent communication skills to schedule appointments, attention to detail and possess a good work ethic. The PCC is responsible for increasing customer satisfaction and...