RN Managed Care Coordintor
Review and Evaluation | Columbia, SC | Contract
RN Managed Care Coordinator
Work Location: Columbia, SC
The RN/Managed Care Coordinator will be responsible for reviewing and evaluating medical or behavior eligibility 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 of clinical experience.
Job Duties/Responsibilities/Functions (including but not limited to)
• Perform medical or behavioral review/authorization process
• Ensure coverage for appropriate services within benefit and medical necessity guidelines
• Assess 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 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.
• Associate degree in Nursing
• 2+ years of clinical experience
• Active and unrestricted RN license in the state of SC
Key Words: Nurse Case Manager, Utilization Review, Registered Nurse, CCM
InGenesis is dedicated to placing people in positions that preserve life, improve lives and inspire others. This does not happen without passionate people, skilled colleagues who are motivated to create innovative solutions and deliver superior service to our clients. Founded in 1998, InGenesis manages thousands of employees, including pioneering healthcare, science, technology and pharma professionals. The workforce solutions company includes almost half of the Fortune 500 in its nearly 300 clients. It is recognized as one of the largest healthcare staffing firms, and InGenesis is the largest minority/women owned healthcare staffing firm in North America.
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.