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Managed Care Coordinator II (31995382)
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.
Essential Duties:
Review and evaluate 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.
Preferred Skills and Abilities:
Working knowledge of Microsoft Office Excel, Access, or other spreadsheet/database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes.
Required Experience:
3 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery. Or, 4 years utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical.
Required Education:
Associate Degree - Nursing, OR, Graduate of Accredited School of Nursing.
PME is an equal opportunity employer. We prohibit discrimination and harassment against any applicant or employee based on any legally recognized basis, including, but not limited to: veteran status, uniformed servicemember status, race, color, religion, sex, sexual orientation, gender identity, age (40 and over), pregnancy, national origin or ancestry, citizenship status, physical or mental disability, genetic information (including testing and characteristics) or any other category protected by federal, state or local law.
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.
Essential Duties:
Review and evaluate 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.
Preferred Skills and Abilities:
Working knowledge of Microsoft Office Excel, Access, or other spreadsheet/database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes.
Required Experience:
3 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery. Or, 4 years utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical.
Required Education:
Associate Degree - Nursing, OR, Graduate of Accredited School of Nursing.
PME is an equal opportunity employer. We prohibit discrimination and harassment against any applicant or employee based on any legally recognized basis, including, but not limited to: veteran status, uniformed servicemember status, race, color, religion, sex, sexual orientation, gender identity, age (40 and over), pregnancy, national origin or ancestry, citizenship status, physical or mental disability, genetic information (including testing and characteristics) or any other category protected by federal, state or local law.
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 Education
Associate Degree
Required Experience
3+ years
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