RN Case Management Coordinator

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

📋 Description

• Delivers proactive care management, evaluates service requirements, and collaborates with members to create and coordinate action plans.

• Oversees services and executes plans, including member objectives.

• Assesses the effectiveness of plans, eligibility, benefit levels, service locations, duration of stay, and medical necessity concerning requested services and benefit exceptions.

• Guarantees precise documentation of clinical data to support and establish medical necessity criteria and contract benefits.

• Provides telephonic assistance for members facing chronic conditions, high-risk pregnancies, or other at-risk situations.

• Engages in direct intervention and patient education with members and healthcare providers concerning the healthcare delivery system.

• May identify, initiate, and take part in on-site evaluations.

• Acts as an advocate for members through ongoing communication and education.

• Encourages enrollment in care management and/or health and disease management programs.

• Delivers appropriate communications (both written and verbal) regarding requested services to healthcare providers and members.

• Conducts medical or behavioral review and authorization processes.

• Ensures coverage for suitable services within benefit and medical necessity guidelines.

• Identifies and refers cases to the appropriate personnel.

⛳️ Requirements

• Associate's degree in a relevant field.

• A minimum of 4 years of recent clinical experience in a defined specialty area, or 4 years in utilization review/case management/clinical settings, with at least 2 of the 4 years being clinical.

• Proficient in word processing software.

• Familiarity with quality improvement processes.

• 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 skills.

• Demonstrated proficiency in spelling, punctuation, and grammar.

• Effective oral and written communication skills, with the ability to persuade, negotiate, or influence others.

• Strong analytical or critical thinking abilities.

• Capacity to manage confidential or sensitive information with discretion.

• An active, unrestricted RN license from the United States, or in the state of hire, OR an active compact multistate unrestricted RN license, OR active, unrestricted licensure as a social worker, counselor, or psychologist.

🏝️ Benefits

• Subsidized health insurance plans.

• Coverage for dental and vision care.

• 401k retirement savings plan with company matching.

• Life insurance coverage.

• Paid Time Off (PTO).

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

• Education assistance programs.

• Recognition for service milestones.

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