Coordinator, Managed Care I

Paladin Consulting, Inc.

Columbia, SC

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JOB DETAILS

SALARY

$30–$30 Per Hour

SKILLS

Academic Intervention, Adjudication, Administrative Policies, Analysis Skills, Case Management, Chronic Disease, Clinical Data Collection, Clinical Information, Clinical Study Publications, Clinical Support, Coaching, Communication Skills, Compensation and Benefits, Customer Support/Service, Data Entry, Database Management Software/Systems (DBMS), Discharge Plans, Disease Prevention and Control, ERISA (Employee Retirement Income Security Act of 1974), Establish Priorities, Health Plan, Healthcare Providers, Interviewing Skills, Maintenance Services, Managed Care, Management of Information Systems/Technology (MIS), Member Orientation, Microsoft Access Database, Microsoft Excel, National Committee for Quality Assurance (NCQA), Needs Assessment, Negotiation Skills, Network Systems, Organizational Skills, Patient Care Authorizations, Patient Education, Persuasion Skills, Presentation/Verbal Skills, Quality of Care, Regulations, Requirements Management, Resource Management, Risk, Spreadsheets, Subrogation, Treatment Plan, Utilization Review Accreditation Commission (URAC), Willing to Travel, Word Processing, Writing Skills

LOCATION

Columbia, SC

POSTED

1 day ago

NON SCA
Contract – NO END DATE PROVIDED
MANAGER WILL CONDUCT VIRTUAL INTERVIEWS
M-F 8:30am – 5pm. No 10hr schedules available currently.
Onsite training for the first week and then can work remotely.
Must live in SC
Hospital experience, UM experience
MANAGER IS LOOKING FOR 3 YEARS EXPERIENCE INSTEAD OF 2 YEARS
Description: office work, at a desk 8 hours per day, reading clinical and processing requests.
Soft Skills:

Strong communication skills, they will talk to providers over phone.
Strong reading comprehension as they will read and interpret medical policies.

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 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.
50% 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. May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
20% 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).
10% Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. Provides telephonic support for members with chronic conditions, high risk pregnancy or other at risk conditions that consist 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.
10% 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.
10% 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. 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. Knowledge of contract language and application. Thorough knowledge/understanding of claims/coding analysis/requirements/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 from one's/out of one's home. May involve some travel within one's community.
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About the Company

Paladin Consulting, Inc.

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