November 6, 2024

Computer Enterprises Inc

Columbia

CONTRACT

RN/Managed Care Coordinator - Remote

Will be required to be on site the 1ST week for training and then will be full remote Must be located no more than 2 hours from Columbia, SC
Required Education: Associate Degree - Nursing or Graduate of Accredited School of Nursing or Master's degree in Social Work, Psychology, or Counseling.
Required Work Experience: 2 years clinical experience.
Required License and Certificate: Active, unrestricted RN licensure in the state of South Carolina

Job Description -

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.
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.
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).

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