RN Health Coach-Behavioral Health Coordinator (ks475-pv)
Nursing | Columbia, SC | Full Time
RN Health Coach-Behavioral Health Coordinator
We have an exciting opportunity for a Registered Nurse to work as a Behavioral Health Coach-Coordinator for our client located in Columbia, SC. This is an exciting opportunity to work for a very large insurance company so if you’re ready to help the wheels of the health care industry remain turning, Apply today!
The Health Coach will provide telephonic support to members. The RN 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.
Responsibilities of Job:
- Telephonic coaching and educating plan members and assisting them with their plan of care.
- Performs medical or behavioral review/authorization process.
- Ensures coverage for appropriate services within benefit and medical necessity guidelines.
- 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).
- Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
- Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
- 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.
- Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. May identify, initiate, and participate in on-site reviews. Serves as member advocate through continued communication and education.
- Promotes enrollment in care management programs and/or health and disease management programs.
- License: Must have an active/in good standing RN license in South Carolina.
- Education: Associate Degree - Nursing, or Graduate of Accredited School of Nursing or Master's degree in Social Work, Psychology, or Counseling.
- Work Experience: 3+ years of Behavioral Health experience required!
We support a diverse workforce and is an Equal Opportunity Employer who does not discriminate against employees and applicants for employment on the basis of race, gender, color, religion, national origin, age, sexual orientation, gender identity, genetic information, disability, veteran status, or other classification protected by law.