Job Title : Managed Care Coordinator

Job Location : Columbia, SC

Top 3 / 5 Skills :

• RN / Registered Nurse License
• Chronic condition care
• Case Management

Job Responsibilities

Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions.

Utilizes clinical proficiency, claims knowledge / analysis, and comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness.

Utilizes available resources to promote quality, cost effective outcomes. these to a lead or manager for resolution. Identifies and reports potential fraud and abuse situations.

Managed Care Coordinator

Job Requirements

6B or Div. 75) or Master's in Psychology, or Counseling.

Required Experience : Recent clinical in defined specialty area. Specialty areas include : oncology, cardiology, neonatology, maternity, rehabilitation services, mental health / chemical dependency, orthopedic, general medicine / surgery.

Or, 4 years’ utilization review / case management / clinical / or combination; 2 of the 4 years must be clinical.

• Required License / Certificate : An active, unrestricted RN license 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)

Last updated : 2024-05-18