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RN / MANAGED CARE COORDINATOR (KS-PV)

Nursing | Columbia, SC | Full Time

Job Description

RN / MANAGED CARE COORDINATOR

We have an opportunity for an RN/Managed Care Coordinator to come and join our client located in Columbia, SC! As the RN/Managed Care Coordinator with a large health insurance provider, you will be responsible for reviewing and evaluating medical or behavior eligibilities regarding benefits and clinical criteria. You’ll successfully complete these highly important assignments by applying clinical expertise, administrative policies and previous established clinical criteria. In this role, you’ll also utilize your clinical proficiency and claims knowledge to assess, plan, implement, coach, coordinator, monitor and evaluate medical necessity. This truly is an exciting opportunity perfect for a professional who has an extensive background in clinical experience.

ROLES AND RESPONSIBILITIES:

  • Perform medical or behavioral review/authorization process
  • Ensure 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
  • Evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay and medical necessity regarding requested services and benefit
  • Ensure accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits
  • Utilize allocated resources to back up review determinations
  • Identify and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.)
  • Participate in data collection/input into the system for clinical information flow and proper claims adjudication
  • Demonstrate 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)
  • Maintain current knowledge of contracts and network status of all service providers and applies appropriately
  • Additional duties as assigned

REQUIRED QUALIFICATIONS:

  • Active and unrestricted RN license in South Carolina
  • Minimum of 2 years clinical experience
  • Solid computer skills
  • Excellent attention to detail
  • Ability to work independently

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.