Coordinator, Managed Care II – UM-1

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

📋 Description

• Conduct medical or behavioral review and authorization processes.

• Ensure coverage for appropriate services in accordance with benefit and medical necessity guidelines.

• Utilize allocated resources to support review determinations.

• Identify and refer to Medical Directors, Case Managers, Preventive Services, Subrogation, and quality-of-care teams.

• Engage in clinical data collection and system input for claims adjudication.

• Adhere to relevant legislation and regulatory guidelines, including ERISA, NCQA, URAC, DOI, and DOL requirements.

• Provide discharge planning and assess service needs with providers and facilities.

• Evaluate plans, eligibility, benefits, place of service, length of stay, medical necessity, and benefit exceptions.

• Document clinical information that supports medical necessity and contract benefits.

• Collaborate with Care Management and other departments to execute care management processes in a timely manner.

• Manage assigned members and authorizations through appropriate communication channels.

• Relay requested-service information to healthcare providers and members both in writing and by phone.

• Engage in patient education and direct intervention regarding healthcare delivery, network utilization, and benefit plans.

• Identify, initiate, and participate in on-site reviews.

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

• Maintain up-to-date knowledge of contracts and provider network status.

• Assist with claims information, discussions, and resolutions; refer issues to internal support areas.

⛳️ Requirements

• Associate's degree in a related field.

• 4 years of recent clinical experience in a specific specialty area, such as oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedics, or general medicine/surgery; OR 4 years of experience in utilization review, case management, clinical work, or a combination thereof, with 2 of those years being clinical experience.

• Proficient in word processing software.

• Understanding of quality improvement processes with proven ability in these activities.

• Familiarity with contract language and its application.

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

• Strong judgment skills.

• Proven customer service, organizational, and presentation skills.

• Proficient in spelling, punctuation, and grammar.

• Excellent oral and written communication skills.

• Ability to persuade, negotiate, or influence others.

• Strong analytical or critical thinking skills.

• Ability to manage confidential or sensitive information with discretion.

• Proficiency in Microsoft Office.

• Active, unrestricted United States RN license and state-of-hire licensure, or active compact multistate unrestricted RN license under the NLC, or active unrestricted United States LMSW license and state-of-hire licensure, or active unrestricted counselor or psychologist licensure and state-of-hire licensure.

• Preferred: bachelor's degree in nursing.

• Preferred: experience in utilization management, project management, supporting large complex employer groups, and HIPAA PHI compliance.

• Preferred: working knowledge of spreadsheet/database software and claims/coding analysis.

• Preferred: Case Manager Certification or clinical certification in a specialty area.

🏝️ Benefits

• Subsidized health plans, dental and vision coverage.

• 401 k retirement savings plan with company match.

• Life Insurance.

• Paid Time Off (PTO).

• On-site cafeterias and fitness centers in major locations.

• Education Assistance.

• Service Recognition.

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