RN Managed Care Coordinator

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

📋 Description

• Evaluate and review medical or behavioral eligibility concerning benefits and clinical criteria for service requests.

• Assess, plan, implement, coordinate, monitor, and analyze medical necessity and/or compliance with care plans, options, and required services.

• Foster quality, cost-effective outcomes by utilizing available resources.

• Conduct medical or behavioral review and authorization processes.

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

• Initiate or coordinate discharge planning and alternative treatment plans as needed.

• Document clinical information that supports medical necessity criteria and contractual benefits.

• Refer to Medical Directors, Case Managers, Preventive Services, Subrogation, Quality of Care Referrals, and other relevant staff.

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

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

• Educate both members and providers about healthcare delivery systems, networks, and benefit plans.

• Act as a member advocate through ongoing communication and education.

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

• Stay informed about contracts and the status of the service-provider network.

• Assist with claims information, discussions, and resolution; refer issues to internal support teams.

• Communicate with healthcare providers and members through telephone and written correspondence.

⛳️ Requirements

• Required Education: Associate's degree in a relevant field.

• Degree Equivalency: Graduate of an Accredited School of Nursing or possess 2 years of relevant work experience.

• A minimum of 2 years of clinical experience.

• Proficiency in word processing software.

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

• Strong judgment abilities.

• Proven skills in customer service, organization, and presentations.

• Demonstrated proficiency in typing, spelling, punctuation, and grammar.

• Effective oral and written communication skills.

• Capability to persuade, negotiate, or influence others.

• Strong analytical and critical thinking skills.

• Ability to manage confidential or sensitive information with discretion.

• Proficiency in Microsoft Office.

• Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR active, unrestricted LMSW licensure from the United States and in the state of hire, OR active, unrestricted licensure as Counselor or Psychologist from the United States and in the state of hire.

• Preferred Education: Bachelor's degree in Nursing.

• Preferred work experience in healthcare program management, utilization review, or clinical experience in a specific specialty.

• Preferred familiarity with spreadsheet and database software.

• Preferred knowledge of contract language and its applications.

• Preferred comprehensive understanding of claims, coding analysis, requirements, and processes.

🏝️ Benefits

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

• 401k retirement savings plan with company match.

• Life Insurance coverage.

• Paid Time Off (PTO).

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

• Education Assistance programs.

• Service Recognition initiatives.

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