Job Title: Managed Care Coordinator I Location: Columbia, SC. 29229 (Remote after 1 weekonsite training) Duration: 2 months assignment with possible extensions Shift: Mon-Fri, 8:30AM - 5:00PM, 40 hours a week
Summary: 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.
Responsibilities:
50% 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.
20% 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).
10% 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 that consist of: intensive assessment/evaluation of condition, at risk education based on members identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement.
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.
Option to work weekends if required.
Required Education: Associate Degree - Nursing or Graduate of Accredited School of Nursing or Master's degree in Social Work, Psychology, or Counseling. Required Work Experience: 2 years clinical experience. Required License and Certificate: Active, unrestricted RN licensure 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), OR, active, unrestricted LMSW (Licensed Master of Social Work) licensure from the United States and in the state of hire, OR active, unrestricted licensure as Counselor, or Psychologist from the United States and in the state of hire.
Preferred Education: Bachelor's degree- Nursing. Preferred Work Experience: 7 years-healthcare program management, utilization review, or clinical experience in defined specialty. Specialty areas are oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery. Languages: English.
About Us: Established in 2004, SPECTRAFORCE® is one of the largest and fastest-growing diversity-owned staffing firms in the US. The growth of our company is a direct result of our global client service delivery model that is powered by our state-of-the-art A.I. proprietary talent acquisition platform, robust ISO 9001:2015/ISO 27001 certified processes, and strong and passionate client engaged teams. We have built our business by providing talent and project-based solutions, including Contingent, Permanent, and Statement of Work (SOW) services to over 140 clients in the US, Canada, Puerto Rico, Costa Rica, and India. Key industries that we service include Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities and Transportation. SPECTRAFORCE is built on a concept of “human connection,” defined by our branding attitude of NEWJOBPHORIA®, which is the excitement of bringing joy and freedom to the work lifestyle so our people and clients can reach their highest potential. Learn more at: http://www.spectraforce.com
Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.
Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at LOA@spectraforce.com if you require reasonable accommodation.
California Applicant Notice: SPECTRAFORCE is committed to complying with the California Privacy Rights Act (“CPRA”) effective January 1, 2023; and all data privacy laws in the jurisdictions in which it recruits and hires employees. A Notice to California Job Applicants Regarding the Collection of Personal Information can be located on our website. Applicants with disabilities may access this notice in an alternative format by contacting NAHR@spectraforce.com.
LA County, CA Applicant Notice: If you are selected for this position with SPECTRAFORCE, your offer is contingent upon the satisfactory completion of several requirements, including but not limited to, a criminal background check. We consider qualified applicants with arrest or conviction records for employment in accordance with all local ordinances and state laws, including the Los Angeles County Fair Chance Ordinance for Employers (FCO) and the California Fair Chance Act (FCA). The background check assessment will consider whether a criminal history could reasonably have a direct, adverse impact on the job-related safety, security, trust, regulatory compliance, or suitability for this role. Such findings may result in withdrawal of a conditional job offer.
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $29.00/hr.