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Managed Care Coordinator UM II

2 months ago

Columbia, United States Experis Full time

Title: Managed Care Coordinator UM II
Location: Columbia SC (Onsite)
Duration: 3 months
Pay Range : $31/hr (On W2)

We are looking for a “ Managed Care Coordinator UM II “to join one of our Fortune 500 clients.

Note:-

  • Training will be onsite & Remote after training

Job Responsibilities:
  • 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 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.

Education:
  • Associate Degree - Nursing, or Graduate of Accredited School of Nursing or Master's degree in Social Work, Psychology, or Counseling.
  • 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), 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. Preferred Licenses and Certificates: Case Manager Certification, clinical certification in specialty area

We are looking for the candidate who are eligible to work with any employers without sponsorship.

If you’re interested, please click “Apply” button.

If you are not available or this job is not a good fit at present, please share the job details with your friends/colleagues and let me know if anyone is interested