Coordinator, Managed Care II/CM-DM

Join our dynamic team in Columbia, SC, where you will have the opportunity to make a significant impact on the health and well-being of our members. Enjoy the vibrant culture and welcoming community of Columbia while advancing your career in a supportive and innovative environment.

Duties

• Review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provide health management program interventions.
• Utilize 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.
• Provide active case management, assess service needs, develop and coordinate action plans in cooperation with members, monitor services, and implement plans, to include member goals.
• Evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• Ensure accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• Provide telephonic support for members with chronic conditions, high-risk pregnancy, or other at-risk conditions.
• Perform medical or behavioral review/authorization process and ensure coverage for appropriate services within benefit and medical necessity guidelines.
• Participate in direct intervention/patient education with members and providers regarding healthcare delivery system, utilization on networks, and benefit plans.
• Maintain current knowledge of contracts and network status of all service providers and apply appropriately.
• Provide appropriate communications (written, telephone) regarding requested services to both healthcare providers and members.
  
  

Skills

Required Skills and Abilities:

• Working knowledge of word processing software.
• Knowledge of quality improvement processes and demonstrated ability with these activities.
• Knowledge of contract language and application.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills.
• Demonstrated customer service, organizational, and presentation skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Demonstrated oral and written communication skills.
• Ability to persuade, negotiate, or influence others.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.
  
  

Required Software and Tools:

• Microsoft Office
  
  

Preferred Skills and Abilities:

• Working knowledge of spreadsheet, database software.
• Thorough knowledge/understanding of claims/coding analysis, requirements, and processes.
  
  

Preferred Software and Other Tools:

• Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software.
  
  

Work Environment

Typical office environment. Employee may work from home. May involve some travel within the community.

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