RN Managed Care Coordinator I

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

📋 Description

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

• Plan, implement, coordinate, monitor, and evaluate medical necessity and compliance with care plans, options, and services.

• Enhance quality and cost-effective outcomes utilizing available resources.

• Conduct medical or behavioral review and authorization processes.

• Ensure coverage for suitable services adhering to benefit and medical necessity guidelines.

• Analyze plans, eligibility, benefit levels, place of service, duration of stay, medical necessity, and benefit exceptions.

• Initiate or coordinate discharge planning and alternative treatment plans when suitable.

• Document clinical information to substantiate medical necessity criteria and contract benefits.

• Identify and refer cases to Medical Directors, Case Managers, Preventive Services, Subrogation, Quality of Care Referrals, and other relevant personnel.

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

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

• Inform members and providers about healthcare delivery systems, network utilization, and benefit plans.

• Advocate for members through continuous communication and education.

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

• Stay updated on contracts and provider network status.

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

• Communicate with healthcare providers and members via telephone and written correspondence regarding requested services.

⛳️ Requirements

• Associate's degree in a relevant field.

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

• Minimum of 2 years of clinical experience.

• Proficient in word processing software.

• Ability to work autonomously, prioritize tasks effectively, and make informed decisions.

• Strong judgment skills.

• Proven customer service, organizational, and presentation abilities.

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

• Effective oral and written communication skills.

• Capability to persuade, negotiate, or influence others.

• Analytical or critical thinking skills.

• Ability to manage confidential or sensitive information with care.

• Proficient in Microsoft Office.

• Active, unrestricted RN licensure from the United States and in the state of employment, 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 employment, OR active, unrestricted licensure as a Counselor or Psychologist from the United States and in the state of employment.

• Preferred: Bachelor's degree in Nursing.

• Preferred: Experience in healthcare program management, utilization review, or clinical experience in a specialized field.

• Preferred: Familiarity with spreadsheet and database software.

• Preferred: Understanding of contract language and its applications.

• Preferred: Comprehensive knowledge of claims, coding analysis, requirements, and processes.

🏝️ Benefits

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

• 401k retirement savings plan with company matching.

• Life insurance.

• Paid Time Off (PTO).

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

• Education assistance.

• Service recognition programs.

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

• A diverse and inclusive workplace.

• Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs.