["Managed Care Coordinator UM II","Managed Care Coordinator UM II"]

As the industry landscape shifts with new challenges in patient care, quality and compliance requirements, workforce retention, and operational efficiencies, we deliver strategic, data-driven solutions that include redefining workforce management and clinical service delivery. Patient Education (5%) : Participate in direct intervention/patient education with members and providers regarding the healthcare delivery system, utilization of networks, and benefit plans.

Managed Care Coordinator UM II

Job Details

Professional Discipline : Registered Nurse

Specialty : Utilization Review

Employment Type : Full Time

City : Columbia

State : SC

Pay Range : 55,000 - 60,000

Job Description:

We are seeking a dedicated Managed Care Coordinator to join our team. This role involves reviewing and evaluating medical or behavioral eligibility for benefits and clinical criteria, applying clinical expertise, administrative policies, and established clinical criteria to service requests. The ideal candidate will utilize their clinical proficiency, claims knowledge, and comprehensive understanding of the healthcare continuum to support members in managing their health, chronic illness, or acute illness.

Schedule: Monday-Friday, 8AM-4:30PM or 8:30AM-5PM

Key Responsibilities:

• Medical/Behavioral Review (50%): Perform medical or behavioral review/authorization processes, ensuring coverage for appropriate services within benefit and medical necessity guidelines. Utilize allocated resources to back up review determinations and make referrals to appropriate staff.
• Discharge Planning (25%): Provide discharge planning and assess service needs in cooperation with providers and facilities. Evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• Communication (15%): Provide appropriate communications (written, telephone) regarding requested services to both healthcare providers and members.
• Patient Education (5%): Participate in direct intervention/patient education with members and providers regarding the healthcare delivery system, utilization of networks, and benefit plans. Promote enrollment in care management programs.
• Claims Assistance (5%): Maintain current knowledge of contracts and network status of all service providers. Assist with claims information, discussion, and/or resolution, and refer to appropriate internal support areas.

Qualifications:

• Education: Associate Degree in Nursing, or Graduate of Accredited School of Nursing, or Master's degree in Social Work, Psychology, or Counseling.
• Experience: 4 years of recent clinical experience in a defined specialty area (e.g., oncology, cardiology, neonatology, etc.) or 4 years of utilization review/case management/clinical experience.
• Licensure: Active, unrestricted RN licensure, or active compact multistate unrestricted RN license, or active, unrestricted LMSW licensure, or active, unrestricted licensure as a Counselor or Psychologist.
• Skills: Strong communication skills, ability to work independently, prioritize effectively, and critical thinking skills. Experience in case management or care coordination and telephonic care experience is preferred.
• Software: Proficiency in Microsoft Office, with preferred knowledge of spreadsheet and database software.

Preferred Qualifications:

• Bachelor's degree in Nursing.
• 7 years of healthcare program management experience.
• Case Manager Certification or clinical certification in a specialty area.

Work Environment:

• Typical office environment with the possibility of working from home after the first week onsite.
• May involve some travel within the community.

EEO Statement:
InGenesis is an equal opportunity employer committed to fostering a diverse, inclusive, and equitable workplace. We comply with all applicable federal, state, and local employment laws, including recent executive orders, and strictly prohibit discrimination, harassment, or retaliation based on race, color, religion, sex, sexual orientation, gender identity, national origin, disability, genetic information, age, veteran status, or any other characteristic protected by law.

InGenesis is dedicated to making reasonable accommodations for qualified individuals with disabilities and ensuring that all employment decisions are based on qualifications, merit, and business needs. If you require a reasonable accommodation during the hiring process, please contact us by visiting our website at

To learn more about your rights, please refer to the Know Your Rights: Workplace Discrimination is Illegal poster issued by the U.S. Equal Employment Opportunity Commission (EEOC).

Company Statement:
With decades of experience, InGenesis has grown into one of North America's most trusted Healthcare Services Firms, which includes comprehensive health and workforce solutions. As the industry landscape shifts with new challenges in patient care, quality and compliance requirements, workforce retention, and operational efficiencies, we deliver strategic, data-driven solutions that include redefining workforce management and clinical service delivery. Explore InGenesis to discover how our expertise, innovative strategies, and commitment to excellence are shaping the future of healthcare workforce solutions. Join us in celebrating the professionals who define the next era of healthcare.