RN/Managed Care Coordinator

Location: Columbia, SC - onsite training required for 4 to 6 weeks, then remote 
Contract: W2 only
Pay: $ 40 /hour + optional medical, dental, vision, 401(k) match
Must live within 2 hours of Columbia, SC
Must have an active, unrestricted RN license in the state of South Carolina
Schedule - M-F 8-430 - 37.5 hour work week with occasional weekend on call schedule

Overview

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.

Key Responsibilities

• 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 discharge planning and assesses service needs in cooperation with providers and facilities.
• 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.
• Collaborates with BCBSSC Care Management and other areas to ensure proper care management processes are executed within a timely manner.
• Manages assigned members and authorizations through appropriate communication.
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
• 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.
• Promotes enrollment in care management programs and/or health and disease management programs.
• 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.

Required Skills

• 4 years recent clinical experience in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery

Required Education

• Associate Degree - Nursing, or Graduate of Accredited School of Nursing 
• Active Unrestricted RN license in the state of South Carolina

Why Should I Apply?

This role offers an opportunity to utilize your clinical expertise in a dynamic environment, supporting members' health management needs. Join a team committed to quality and cost-effective healthcare outcomes.

About CEI:
As a trusted technology partner, CEI delivers solutions that help our customers transform their business and achieve meaningful results. From strategy and custom application development through application management - our technology and digital experience services are tailored to meet each unique need of our customers. Our staffing solutions bring specialized skills to complement our customers' workforce and project requirements.

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