Job Description

Job Description

Job Description

Must live within 2 hours of Columbia, SC
Must have an active, unrestricted RN license in the state of South Carolina

Pay Rate: $31.25/hr 
Schedule: Monday–Friday, 8:30 AM–5:00 PM
Location: Remote w/ first week of onsite training in Columbia, SC Role Overview

The Managed Care Coordinator will provide case management and utilization management services to members via phone. The role involves managing a caseload of 50–60 members per month, coordinating care, and collaborating with providers and internal teams

Key Responsibilities

Case Management & Member Support

• Provide active case management by assessing service needs, developing action plans, and coordinating care with members
• Monitor services and implement plans based on member goals
• Evaluate outcomes, eligibility, benefits, and medical necessity
• Document clinical information to support decisions
• Deliver telephonic support for members with chronic or at-risk conditions
• Use motivational interviewing and readiness-to-change techniques to promote engagement

Medical/Behavioral Review & Authorization

• Perform reviews to ensure coverage within benefit and medical necessity guidelines
• Refer cases to appropriate internal staff (e.g., Medical Director, Case Manager)
• Input clinical data for proper claims adjudication
• Ensure compliance with applicable regulations (ERISA, NCQA, URAC, DOI, DOL)

Education & Advocacy

• Educate members and providers on healthcare delivery, network utilization, and benefits
• Promote enrollment in care and disease management programs
• Serve as a member advocate through ongoing communication

Contract & Claims Support

• Maintain knowledge of provider contracts and network status
• Assist with claims discussions and resolutions
• Refer to internal teams for processing support

Communication

• Provide clear and professional written and verbal communications to providers and members regarding service requests

Required Skills & Tools

• Proficiency in Microsoft Office
• Familiarity with quality improvement processes
• Understanding of contract language
• Strong organizational and customer service skills
• Analytical and critical thinking abilities

Education & Experience Requirements

Required Education:

• Associate Degree in Nursing, OR
• Graduate of Accredited School of Nursing, OR
• Master’s in Social Work, Psychology, or Counseling (depending on division)

Required Experience:

• 4 years recent clinical experience in a specialty area (e.g., oncology, cardiology, maternity, mental health, etc.)
  OR
• 4 years in utilization review/case management/clinical roles (2 years must be clinical)

Required Licensure:

• Active, unrestricted RN license (state-specific or compact multistate)
  OR
• Active, unrestricted license as social worker, counselor, or psychologist (division-specific)

#INDGEN #ZR 

Job Tags

Contract work, Work at office, Monday to Friday,

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