Clinical Case Manager

1 week ago


Columbia, South Carolina, United States US Tech Solutions Full time
Job Description:

We are seeking a highly skilled Registered Nurse to join our team as a Case Manager. As a Case Manager, you will be responsible for providing telephonic case management services to our members, working closely with healthcare providers and other stakeholders to ensure high-quality care.

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.
  • Provides telephonic support for members with chronic conditions, high-risk pregnancy, or other at-risk conditions, including intensive assessment/evaluation of condition, at-risk education based on members' identified needs, and member-centered coaching utilizing motivational interviewing techniques.
  • Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
  • Participates in data collection/input into system for clinical information flow and proper claims adjudication.
Requirements:
  • 4 years of recent clinical experience in a defined specialty area, such as oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, or general medicine/surgery.
  • Working knowledge of word processing software, quality improvement processes, and contract language and application.
  • Ability to work independently, prioritize effectively, and make sound decisions.
  • Good judgment skills, customer service, organizational, and presentation skills.
About US Tech Solutions:

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. We are an Equal Opportunity Employer and welcome applications from qualified candidates without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.


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