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Managed Care Coordinator I (31609005)
Columbia, SC
Job Description
Seeking anRNwithManaged Care and Utilization Managementexperience to review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria. This position is remote, but requires the candidate to reside in the state of S.C. The scheduled is M-F 8:30am-5:00pm.
It is the policy of the Company to provide equal employment opportunities to all qualified individuals and to administer all aspects and conditions of employment without regard to the following:
• Race and associated traits, including hairstyle; Color, Age, Sex, Sexual orientation, Gender, Gender identity and gender expression; Religion, including dress and grooming practices; National origin, including language use restrictions; Pregnancy, childbirth, or breastfeeding; Marital or familial status; Genetic information, including family medical history; Physical or mental disability; Citizenship and/or immigration status
• Medical conditions, including cancer, AIDS/HIV, and occupational pneumoconiosis without respiratory impairment
• Denial of family or medical care leave
• Use of a guide or support animal
• Military or veteran status
• Political activities or affiliations
• Exercise of civil rights
• Domestic violence, assault, or stalking victim status
• GED certificate
• Arrest, expunged, or sealed records
• Application for or enrollment in Medi-Cal
• Status as a smoker or non-smoker
• Credit report or credit information
• Child or spousal support withholding
• Wage garnishment for consumer debt
• Relationship with someone with a disability
• Lawful conduct occurring during nonworking hours not on Company premises
• Any other protected class, in accordance with applicable federal, state, and local laws
Discriminatory, harassing, or retaliatory behavior is prohibited from coworkers, supervisors, managers, owners, and third parties, including clientele. The Company takes allegations of discrimination, harassment and retaliation very seriously and will promptly conduct an investigation when warranted. Equal employment opportunity includes, but is not limited to, employment, training, promotion, demotion, transfer, leaves of absence and termination.
- Utilizes clinical proficiency and claims knowledge/analysis to assess, plan, implement, health coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, 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.
- Performs medical or behavioral review/authorization process.
- Ensures 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.
- Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
It is the policy of the Company to provide equal employment opportunities to all qualified individuals and to administer all aspects and conditions of employment without regard to the following:
• Race and associated traits, including hairstyle; Color, Age, Sex, Sexual orientation, Gender, Gender identity and gender expression; Religion, including dress and grooming practices; National origin, including language use restrictions; Pregnancy, childbirth, or breastfeeding; Marital or familial status; Genetic information, including family medical history; Physical or mental disability; Citizenship and/or immigration status
• Medical conditions, including cancer, AIDS/HIV, and occupational pneumoconiosis without respiratory impairment
• Denial of family or medical care leave
• Use of a guide or support animal
• Military or veteran status
• Political activities or affiliations
• Exercise of civil rights
• Domestic violence, assault, or stalking victim status
• GED certificate
• Arrest, expunged, or sealed records
• Application for or enrollment in Medi-Cal
• Status as a smoker or non-smoker
• Credit report or credit information
• Child or spousal support withholding
• Wage garnishment for consumer debt
• Relationship with someone with a disability
• Lawful conduct occurring during nonworking hours not on Company premises
• Any other protected class, in accordance with applicable federal, state, and local laws
Discriminatory, harassing, or retaliatory behavior is prohibited from coworkers, supervisors, managers, owners, and third parties, including clientele. The Company takes allegations of discrimination, harassment and retaliation very seriously and will promptly conduct an investigation when warranted. Equal employment opportunity includes, but is not limited to, employment, training, promotion, demotion, transfer, leaves of absence and termination.
Job Summary
Start Date
As soon as possible
Employment Term and Type
Regular, Full Time
Required Experience
Open
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