Case Management Coordinator – Oncology Focus

This is a fully remote position, open to applicants in South Carolina.

📋 Description

• Deliver proactive care management and evaluate the service requirements of members.

• Create and coordinate action plans centered around members and oversee service delivery.

• Assess outcomes of plans, eligibility, benefit levels, service locations, duration of stay, medical necessity, and exceptions to benefits.

• Accurately document clinical information to support determinations of medical necessity and contractual benefits.

• Offer telephonic assistance to members dealing with chronic conditions, high-risk pregnancies, or other high-risk situations.

• Conduct thorough assessments, risk education, coaching, motivational interviewing, reflective listening, and readiness-to-change evaluations.

• Engage in direct interventions and educate patients and providers about healthcare delivery, networks, and benefit plans.

• Identify, initiate, and take part in on-site reviews as necessary.

• Act as an advocate for members by maintaining ongoing communication and education.

• Encourage participation in care management and health/disease management programs.

• Communicate with healthcare providers and members regarding services requested.

• Execute medical or behavioral review and authorization protocols.

• Ensure that service coverage aligns with benefit and medical necessity guidelines.

• Make referrals to Medical Directors, Case Managers, Preventive Services, Subrogation, Quality of Care Referrals, and other relevant personnel.

• Contribute to clinical data collection and system entry for the flow of clinical information and claims adjudication.

• Adhere to applicable laws and regulatory standards, including ERISA, NCQA, URAC, DOI, and DOL compliance.

• Stay updated on contract details and provider network statuses.

• Assist with claims information, discussions, and resolutions, directing issues to internal support teams.

⛳️ Requirements

• An Associate's degree in a relevant field.

• Graduation from an accredited nursing school or two years of relevant work experience.

• Four years of recent clinical experience in a specific specialty area, including oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, or general medicine/surgery.

• Alternatively, four years of experience in utilization review, case management, or clinical settings, with two of those years in a clinical role.

• Proficient in word processing software.

• Familiarity with quality improvement processes and demonstrable experience in these activities.

• Understanding of contract language and its application.

• Capability to work independently, prioritize tasks effectively, and make informed decisions.

• Strong judgment skills.

• Proven customer service, organizational, and presentation abilities.

• Demonstrated proficiency in spelling, punctuation, and grammar.

• Effective oral and written communication skills.

• Ability to persuade, negotiate, or influence others.

• Strong analytical or critical thinking skills.

• Competence in handling confidential or sensitive information with care.

• Proficiency in Microsoft Office.

• An active, unrestricted RN license from the United States and the state of hire, or an active compact multistate unrestricted RN license under the Nurse Licensure Compact, or applicable unrestricted licensure as a social worker, counselor, or psychologist.

• For Div. 75 and Div. 6B, excluding CC 426: URAC-recognized Case Management Certification must be obtained within four years of employment as a Case Manager.

• Preferred: A Bachelor's degree in Nursing.

• Preferred: Over three years of experience in Oncology.

• Preferred: Knowledge of spreadsheet and database software.

• Preferred: Familiarity with claims/coding analysis, requirements, and processes.

• Preferred: Case Manager certification and clinical certification in the relevant specialty area.

🏝️ Benefits

• Subsidized health plans, along with dental and vision coverage.

• 401k retirement savings plan with company matching contributions.

• Life insurance coverage.

• Paid Time Off (PTO).

• Onsite cafeterias and fitness centers available at major locations.

• Educational assistance programs.

• Service recognition initiatives.

• National discounts available for movies, theaters, zoos, theme parks, and more.