Managed Care Coordinator # 26-26439

Duration: 3 Months (Possible contract to hire)
 
Job Description:

• 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 and claims knowledge/analysis to assess, plan, implement, health coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, 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.
• Prior hospital experience and stable work history is required. Prior utilization management and/or case management experience is preferred but not required.
• Candidates must be comfortable learning and navigating multiple computer systems quickly.
  
  

Daily Responsibilities:

• Review inpatient admissions and continued stays for hospitals, skilled nursing facilities, rehabilitation facilities, and LTAC facilities using Milliman/MCG/InterQual and company policies.
• Prepare clinical summaries for medical director review when criteria are not met.
• Draft letters using company templates and coordinate with case management, transplant coordinators, team leads, medical directors, and supervisors.
• Attend monthly and quarterly Teams meetings.
• Remote role after approximately 3-4 days onsite.

 
Responsibilities:

• Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits (50%).
• Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.). Participates in data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal) (20%).
• Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. Provides telephonic support for members with chronic conditions, high risk pregnancy or other at risk conditions, including intensive assessment/evaluation of condition, at risk education based on members' identified needs, and member-centered coaching using motivational interviewing techniques, reflective listening, and readiness to change assessment (10%).
• Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services (10%).
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members (10%).
• Review inpatient admissions and continued stays for hospitals, skilled nursing facilities, rehabilitation facilities, and LTAC facilities using Milliman/MCG/InterQual and company policies. Prepare clinical summaries for medical director review when criteria are not met. Draft letters using company templates and coordinate with case management, transplant coordinators, team leads, medical directors, and supervisors. Attend monthly and quarterly Teams meetings.
• Once off orientation, close at least 15 cases daily, with consideration for case complexity.

 
Experience:

• Required: 2 years of clinical experience. Prior hospital experience and a stable work history are required by the manager. New graduates and candidates without hospital experience will not be considered.
• Preferred: Utilization management and/or case management experience; 7 years of healthcare program management, utilization review, or clinical experience in a defined specialty (oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery)

 
Skillsets:

• Working knowledge of word processing software.
• 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.
• 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.
• Ability to learn and navigate multiple computer systems quickly.
• Microsoft Office.
• Preferred: Working knowledge of spreadsheet and database software (Excel, Access), knowledge of contract language and application, and thorough knowledge of claims/coding analysis, requirements, and processes.
• Soft Skills: Positive attitude, willingness to learn, flexibility, sound judgment, and proactive communication. Candidates should be comfortable asking questions and seeking clarification. Frequent monitoring of email and Teams is expected because priorities and policies may change throughout the day.

 
Education:

• Associate Degree in Nursing or graduate of an accredited school of nursing.
• Preferred: Bachelor's Degree in Nursing.

 
License:

• Active, unrestricted South Carolina RN license or active compact multistate RN license (Nurse Licensure Compact).

 
Shift Hours: 8:30 AM - 5:00 PM, Monday to Friday
 
 
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.
 
US Tech Solutions is an Equal Opportunity Employer.  All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
 
AI Statement: By applying, you acknowledge that AI-assisted tools may be used during hiring. 

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