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Managed Care Coordinator UM II

1 month ago

West Columbia, United States Experis Full time
  • Title: Managed Care Coordinator UM II
  • Location: Initial on-site work required for the first week, followed by remote work.
  • Hours: Monday-Friday, 8:00 AM-4:30 PM or 8:30 AM-5:00 PM.
  • Pay Range: $25 to $31.25/hr.
  • Duration: 4 months (hight possibility for an extension)
Role Overview
This role involves reviewing and evaluating medical or behavioural eligibility for benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests. The individual will also provide health management program interventions, utilizing clinical proficiency, claims knowledge, and comprehensive understanding of the healthcare continuum to support members in managing their health, chronic or acute illnesses.
Key Responsibilities
  • Medical or Behavioral Review & Authorization Process (50%)
    • Perform review and authorization processes to ensure coverage within benefit and medical necessity guidelines.
    • Utilize resources to support review determinations.
    • Identify and make referrals to appropriate staff (e.g., Medical Director, Case Manager, Preventive Services, etc.).
    • Participate in data collection/input into the system for clinical information flow and claims adjudication.
    • Demonstrate compliance with applicable regulations and guidelines, including ERISA, NCQA, URAC, DOI, and DOL.
  • Discharge Planning & Service Needs Assessment (25%)
    • Work with providers and facilities to coordinate discharge planning and assess service needs.
    • Evaluate outcomes related to service plans, eligibility, level of benefits, place of service, length of stay, and medical necessity.
    • Ensure accurate documentation of clinical information to determine medical necessity and contract benefits.
    • Collaborate with Care Management and other areas for timely care management execution.
    • Manage assigned members and authorizations through appropriate communication channels.
  • Provider and Member Communication (15%)
    • Provide written and telephonic communications regarding requested services to both healthcare providers and members.
  • Direct Intervention/Patient Education (5%)
    • Engage in direct intervention or patient education regarding healthcare delivery systems, network utilization, and benefit plans.
    • Promote enrollment in care management programs or health and disease management programs.
  • Contract and Network Knowledge Maintenance (5%)
    • Maintain up-to-date knowledge of contracts and network status for all service providers and apply appropriately.
    • Assist with claims information, discussion, or resolution, and refer to internal support as needed.
Preferred Skills & Qualities
  • Technical Skills:
    • Working knowledge of spreadsheet and database software.
  • Experience:
    • Background in case management or care coordination, and telephonic care experience.
  • Soft Skills:
    • Strong communication skills, active listening, adaptability, and time management.

Interviews: Panel interviews conducted via MS Teams.
To Apply: Please attached you most recent resume.