Clinical Coordinator

4 days ago


West Columbia, South Carolina, United States Hornet Staffing, Inc. Full time
Job Summary

We are seeking a highly skilled Clinical Coordinator to join our team at Hornet Staffing, Inc. As a Clinical Coordinator, you will play a critical role in reviewing and evaluating medical or behavioral eligibility regarding benefits and clinical criteria.

Key Responsibilities
  • Medical or Behavioral Review/AUTHORIZATION PROCESS: Ensure coverage for appropriate services within benefit and medical necessity guidelines. Assess service needs, develop and coordinate action plans in cooperation with members, monitor services and implement plans. Evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
  • Discharge Planning and Alternative Treatment Plans: May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensure accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
  • Data Collection and Input: Utilize allocated resources to back up review determinations. Identify and make referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.). Participate in data collection/input into system for clinical information flow and proper claims adjudication.
  • Regulatory Compliance: Demonstrate 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).
  • Patient Education and Advocacy: Provide 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.
Requirements
  • Education and Experience: RN License, Acute Clinical, Registered Nurse, Presentation Skills, Claims, Coding, Database, Managed Care, Contracts, Microsoft Excel, Discharge Planning, Retail Sales, Documentation, Oncology, Microsoft Office, Data Collection, Mental Health, Financial Project Management
  • Skills and Abilities: Working knowledge of word processing software, ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.
Work Environment

Typical office environment. Employee may work from one's/out of one's home. May involve some travel within one's community.


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