Coordinator, Managed Care I

4 weeks ago

Columbia, United States US Tech Solutions, Inc. Full time
Job Description:
  • Mon-Fri 8:30-5. REMOTE Teams interview with two department members 1-week onsite training.
  • NICE TO HAVE skill sets/qualities: Computer and typing skills are a must as we use several different programs and work remotely. Detail Oriented, Good Communication Skills, Time Management, Organization, Team Oriented, but able to work independently.
  • A typical day would like in this role: We would sign on the computer at 8:30am and check the workload and begin prioritizing the day. The faxes come in electronically and we get requests via phone as well. We would check for date of service or due date to determine the priority of our cases. Then we review the requests against the policy and the member’s contract. When reviewing the clinical we determine if it can be reviewed at our level. If not, then it would be sent for review with our medical director. We would then complete the approval or denial and notify the provider.
  • Strong communication skills are needed as they will communicate with members, providers.
  • We have a very team centered approach. We all work together to accomplish our goals and to provide the best services possible for our members. We work closely with other UM teams in our department. My team currently has 12 nurses on staff. We offer team building activities and like to get know our team members. We are looking for someone that will be interested in our team culture.              
 
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 and claims knowledge/analysis to assess, plan, implement, health coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, 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. Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
  • 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). Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. Provides 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. 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. Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
 
Experience:
  • 2 years clinical experience.
 
Skills:
  • 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. Required Software and Tools: Microsoft Office. Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Knowledge of contract language and application. Thorough knowledge/understanding of claims/coding analysis/requirements/processes. Preferred
  • Software and Other Tools: Working knowledge of Microsoft Excel, Access or other spreadsheet/database software. Work Environment: Typical office environment. Employee may work from one's/out of one's home. May involve some travel within one's community.
 
Education:
  • Associate Degree - Nursing or Graduate of Accredited School of Nursing or Master's degree in Social Work, Psychology, or Counseling.
 
 
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. To know more about US Tech Solutions, please visit www.ustechsolutions.com.
 
US Tech Solutions is an Equal Opportunity Employer.  All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity,
national origin, disability, or status as a protected veteran.

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