Managed Care Coordinator UM II

Join our dynamic team in Columbia, SC, where you will have the opportunity to make a meaningful impact on members' health and well-being. Our organization is committed to providing quality care and ensuring cost-effective outcomes for our members.

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.
• Utilize clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of the 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.
• Perform medical or behavioral review/authorization processes and ensure coverage for appropriate services within benefit and medical necessity guidelines.
• Participate in data collection/input into the system for clinical information flow and proper claims adjudication.
• Provide discharge planning and assess service needs in cooperation with providers and facilities.
• Provide appropriate communications (written, telephone) regarding requested services to both healthcare providers and members.
• Participate in direct intervention/patient education with members and providers regarding the healthcare delivery system, utilization on networks, and benefit plans.
• Maintain current knowledge of contracts and network status of all service providers and apply appropriately.
  
  

Skills

• Required Software and Other Tools: Microsoft Office.
• Preferred Skills and Abilities: Working knowledge of spreadsheet, database software, claims/coding analysis, requirements, and processes.
• Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software.
  
  

Preferred / Nice-to-Have Skills

• Utilization Management (UM) experience
• Appeals processing experience
• Strong clinical skills
• Behavioral Health or infusion therapy experience
  
  

Day-to-Day Responsibilities

• Process prior authorization requests for Medicare Advantage line of business
• Review and apply Medicare criteria to authorization requests
• Process appeals requests
• Work in Utilization Management or Appeals workflows
• Collaborate with team members to ensure timely movement of authorization requests
• Utilize multiple applications to process authorizations and appeals
  
  

Not Looking For

• Candidates with multiple short-term jobs in a short time span
• Candidates who do not live locally
• Candidates without medical or clinical experience
  
  

Soft Skills (Required)

• Strong ability to process authorization requests accurately and timely
• Excellent written clinical documentation skills
• Effective verbal and written communication
• Ability to collaborate with team members to move work efficiently
• Adaptable and able to perform in a fast-paced environment
  
  

Team Environment

• Fast-paced and highly interactive team
• Works across multiple applications
• Supports authorization and appeals processing
• Operates using Medicare criteria
• High-volume, deadline-driven workflow