Case Management Coordinator

CONTRACT ONLY – NO END DATE PROVIDED
NON SCA
PLEASE ENSURE THE CANDIDATES SUBMITTED KNOW WHAT POSITION THEY ARE BEING SUBMITTED TO AND WHAT THE REQUIREMENTS ARE.
Monday through Friday, 8:30 am -5:00 pm. Two late shifts until 8:00 pm per month, 11:30 am - 8:00 pm, no late shifts on Fridays
Onsite training at our Percival Road office in Columbia SC for the first week.
At the end of the week, they will be deployed home with equipment and will work remotely
Candidates must be within 2 hours of the Percival Road location
Client will provide equipment.
Employees will have to have high-speed internet service that can be plugged directly into the computer. Employees must provide their own desk, chair, and a room with a door that closes in which they can work within their home.
No people in the home can be in the room while the employee is working.
Associates can't be the primary caregiver for a child or adult, while they are working.

Skills:

• Please list out the top 2-4 PREFERRED/NICE TO HAVE skill sets/qualities:
• PLEASE REVIEW MINIMUM REQUIREMENTS FOR JOB

• Please provide a few sentences describing what a typical day would like in this role:
Employees will be providing telephonic case management for our members.
• Please add a few bullets of what you're NOT looking for experience wise (this really helps the vendors in their search and narrowing down the candidate pool): Past job instability.
Registered nurses MUST have 4 years or more of RECENT clinical experience.
• Please list any 'soft skills' (communication, leadership, adaptable etc.) that you would like candidates to have and the importance of these skills for this role (ex – do they need strong communication skills because they will be a part of team presentations?)
Strong communication skills are required to provide telephonic case management to patients and to coordinate with team, providers, and patient representatives regarding patient care.
**LOOKING FOR CANDIDATES THAT HAVE RECENT ADULT CARE EXPERIENCE.**
**PLEASE ENSURE YOU ARE BEING SPECIFIC WITH THE TYPE OF AREAS/DUTIES THE CANDIDATE HAS PERFORMED WITHIN THEIR PREVIOUS POSITIONS.**
Adaptability for changes in case management processes.
Our team works well together to care for our members and support each other

Duties:

• 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.
• 60% 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.
• Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. Provides telephonic support for members with chronic conditions, high risk pregnancy or other at risk conditions thatconsist of: intensive assessment/evaluation of condition, at risk education based on members' identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement.
• 20% 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 isnot limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal).
• 10% 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. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs.
• 5% 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.
• 5% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
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Skills:
Required Skills and Abilities:

• Working knowledge of word processing software. Knowledge of quality improvement processes and demonstrated ability with these activities. Knowledge of contract language and application. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.
• Required Software and Tools: Microsoft Office.
• Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes.
• Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software.
• Work Environment: Typical office environment. Employee may work form one's/out of one's home. May involve some travel within one's community.
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