Coordinator, Managed Care II/CM-DM

6 days ago

Columbia, United States Experis Full time

Title: Coordinator, Managed Care II
Location: (Remote OR Hybrid) 17 Technology Circle Columbia SC 29203 US
Duration: 03+ Month’s Contract
Pay Range $30.00 to $36.00/hr.

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

Job Summary
The Case Manager - Clinical Review Specialist is responsible for reviewing and evaluating medical or behavioral eligibility for benefits and applying clinical expertise, administrative policies, and established clinical criteria to service requests. The role involves managing and coordinating care for members, assessing service needs, and ensuring high-quality, cost-effective healthcare outcomes. The ideal candidate will use their clinical knowledge to determine medical necessity, coordinate healthcare services, and promote patient-centered care.

Responsibilities:
Active Case Management (60%)

  • Provide case management services by assessing member needs, developing and implementing action plans in cooperation with the member, and coordinating services.
  • Evaluate service plans, determine eligibility, and assess medical necessity for services, including benefit exceptions.
  • Monitor the progress of the action plans, track member goals, and ensure proper documentation of clinical information.
  • Offer telephonic support for members with chronic conditions, high-risk pregnancies, or other at-risk conditions.
  • Use motivational interviewing techniques and member-centered coaching to promote engagement in health programs and behavior change.
Medical or Behavioral Review/Authorization (20%)
  • Perform medical and behavioral service reviews and authorizations based on benefit and medical necessity guidelines.
  • Ensure appropriate service coverage by utilizing allocated resources and making necessary referrals to relevant departments (e.g., Medical Director, Case Manager, Quality of Care, etc.).
  • Maintain compliance with legislation and regulatory guidelines, including ERISA, NCQA, URAC, State DOI, and Federal DOL standards.
  • Collect and input data for clinical information flow and claims adjudication.
Patient Education and Advocacy (10%)
  • Educate members and healthcare providers about the healthcare delivery system, network utilization, and benefit plans.
  • Promote care management, health, and disease management programs by engaging members in enrollment.
  • Serve as an advocate for members through consistent communication and support.
Knowledge of Contracts and Networks (5%)
  • Maintain up-to-date knowledge of provider contracts and network status to ensure appropriate application in service authorizations.
  • Assist in resolving claims issues and facilitate proper claims processing for authorized services.
Communication (5%)
  • Provide timely written and telephonic communication to both healthcare providers and members regarding requested services.
  • Coordinate effectively with internal teams to ensure service delivery and problem resolution.

Requirements:
  • Education/Certification: Associate’s or Bachelor’s degree in Nursing, Social Work, or a related healthcare field. Active RN or LCSW license required.
  • Experience: Minimum 3-5 years of clinical experience in case management, healthcare coordination, or medical review, with a focus on chronic illness, high-risk pregnancies, or acute illness.

Knowledge & Skills:
  • Strong understanding of medical necessity, claims knowledge, and healthcare continuum.
  • Proficient in motivational interviewing, reflective listening, and readiness to change assessment.
  • Excellent communication skills, both verbal and written.
  • Familiarity with regulations including ERISA, NCQA, URAC, DOI, and DOL.
  • Experience in utilizing healthcare management software and systems for claims adjudication and data entry.

Additional Information:
  • Work Environment: Primarily remote with hybrid options, dependent on the pace and competency validation of the employee. Initial training will be conducted onsite, with all travel expenses covered by Client.
  • On-Call Requirement: On-call responsibilities will begin 3 months after training, with call hours being less than 6 hours per assigned weekend.


Interview process:
Face-to-Face or Video (depending on proximity)

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

If you are 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.

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