Coordinator, Managed Care II/CM-DM

About the Role

This position involves reviewing and evaluating medical or behavioral eligibility for benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests. The role also includes providing health management program interventions, active case management, and telephonic support for members with chronic or high-risk conditions.

Responsibilities

• Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria.
• Provides active case management, including assessing service needs, developing and coordinating action plans, and monitoring services to support members in managing their health, chronic illness, or acute illness (60% of role).
• Performs medical or behavioral review/authorization process to ensure coverage for appropriate services within benefit and medical necessity guidelines (20% of role).
• Participates in direct intervention and patient education with members and providers regarding healthcare delivery, utilization of networks, and benefit plans (10% of role).
• Maintains current knowledge of contracts and network status of service providers and assists with claims information and resolution (5% of role).
• Provides appropriate communications (written, telephone) regarding requested services to healthcare providers and members (5% of role).
• Utilizes clinical proficiency, claims knowledge, and comprehensive understanding of the healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity and services.
• Ensures accurate documentation of clinical information to support medical necessity criteria and contract benefits.
• Provides telephonic support for members with chronic conditions, high-risk pregnancies, or other at-risk conditions, including intensive assessment, education, and member-centered coaching.
• Identifies and makes referrals to appropriate staff (e.g., Medical Director, Case Manager, Preventive Services).
• Participates in data collection and input for clinical information flow and proper claims adjudication.
• Demonstrates compliance with applicable legislation and guidelines (e.g., ERISA, NCQA, URAC, DOI, DOL).
• Promotes enrollment in care management, health, and disease management programs.
• Serves as a member advocate through continued communication and education.

Requirements

• Must be a Registered Nurse (RN) with a valid South Carolina nursing license.
• Must live in South Carolina.
• Experience in critical care, ICU, ER, cardiac PACU, progressive care unit, or step-down units.
• Appeals and reconsideration experience preferred.
• Utilization management experience preferred.
• Prior experience working for a health insurance company and/or with the Medicare population.
• Flexibility and dependability; ability to assist other departments as needed.
• Strong analytical skills; ability to assess each case individually.
• Knowledge of MS Office (Outlook, Teams, Excel) and ability to learn and work with multiple systems simultaneously.
• Ability to work independently and meet productivity goals without constant direction.

Skills

• Required Skills and Abilities:
  • Working knowledge of word processing software.
  • Knowledge of quality improvement processes.
  • Knowledge of contract language and application.
  • Ability to work independently, prioritize effectively, and make sound decisions.
  • Good judgment and customer service skills.
  • Strong organizational and presentation skills.
  • Proficiency in spelling, punctuation, and grammar.
  • Strong oral and written communication skills.
  • Ability to persuade, negotiate, or influence others.
  • Analytical and 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 and database software.
  • Thorough knowledge of claims/coding analysis, requirements, and processes.
• Preferred Software and Tools:
  • Microsoft Excel, Access, or other spreadsheet/database software.

Work Environment

Typical office environment. The employee may work from home and may involve some travel within the community.

Schedule

• Hours: 8:00 AM – 4:30 PM, Monday through Friday.
• On-call every 4-6 weeks once fully trained (on-call will not begin for at least 3 months).
• Call hours are typically less than 6 hours per assigned weekend, with exceptions reviewed by management.
• Training is onsite for at least 4 weeks (travel is covered/reimbursed by the client).
• Remote/hybrid work depends on employee pace and validation of competency.
• On-call hours include weekends and holidays.

Pay

Maximum pay rate: ***/HR (non-SCA contract-to-hire role).