Talent Software Services
Position Overview:
The
Coordinator, Managed Care I
is responsible for reviewing and evaluating medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical guidelines to service requests. This role also supports health management interventions by utilizing clinical proficiency and claims knowledge to assess, plan, implement, coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance. The goal is to support members in managing their health, chronic illness, or acute illness while promoting quality, cost-effective outcomes.
Key Duties & Responsibilities 50% - Medical/Behavioral Review & Authorization Perform medical or behavioral review/authorization process. Ensure coverage for appropriate services within benefit and medical necessity guidelines. Assess service needs, develop and coordinate action plans, monitor services, and implement plans. Evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services. Initiate/coordinate discharge planning or alternative treatment plans as appropriate. Ensure accurate documentation of clinical information supporting medical necessity and benefits.
20% - Referrals & Compliance Utilize allocated resources to back up review determinations. Identify and make referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.). Participate in data collection/input into systems for clinical information flow and claims adjudication. Demonstrate compliance with ERISA, NCQA, URAC, DOI (State), DOL (Federal), and other regulatory requirements.
10% - Member & Provider Education Participate in direct intervention/patient education with members and providers. Serve as a member advocate through communication and education. Promote enrollment in care management or health/disease management programs. Provide telephonic support for members with chronic conditions, high-risk pregnancy, or other at-risk conditions. Conduct intensive assessments, risk-based education, and member-centered coaching using motivational interviewing techniques.
10% - Provider/Claims Coordination Maintain current knowledge of contracts and provider networks. Assist with claims information, discussions, or resolutions. Refer to appropriate internal support areas to ensure proper processing of services.
10% - Communication & Documentation Provide appropriate written and telephonic communications regarding requested services to both healthcare providers and members.
Skills & Competencies
Required Skills:
Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Strong judgment, customer service, organizational, and presentation skills. Proficiency in oral/written communication, spelling, punctuation, and grammar. Persuasion, negotiation, and influencing abilities. Analytical and critical thinking skills. Ability to handle confidential/sensitive information with discretion. Required Software & Tools:
Microsoft Office Preferred Skills:
Working knowledge of spreadsheet and database software. Knowledge of contract language and application. Thorough understanding of claims/coding analysis, requirements, and processes. Preferred Software & Tools:
Microsoft Excel, Access, or other database/spreadsheet software. Work Environment
Typical office environment. May involve work-from-home arrangements. May require some local travel within the community. Education & Experience Requirements
Required Education:
Associate Degree in Nursing
OR
Graduate of Accredited School of Nursing
OR
Master's degree in Social Work, Psychology, or Counseling. Required Experience:
2 years of clinical experience. Required Licensure/Certification:
Active, unrestricted RN license (United States and state of hire)
OR Active compact multistate unrestricted RN license (NLC)
OR Active, unrestricted LMSW license (United States and state of hire)
OR Active, unrestricted licensure as Counselor or Psychologist (United States and state of hire). Preferred Education:
Bachelor's Degree in Nursing. Preferred Experience:
7 years of healthcare program management, utilization review, or clinical experience in a specialty area (oncology, cardiology, neonatology, maternity, rehab services, mental health/chemical dependency, orthopedics, or general medicine/surgery).
The
Coordinator, Managed Care I
is responsible for reviewing and evaluating medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical guidelines to service requests. This role also supports health management interventions by utilizing clinical proficiency and claims knowledge to assess, plan, implement, coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance. The goal is to support members in managing their health, chronic illness, or acute illness while promoting quality, cost-effective outcomes.
Key Duties & Responsibilities 50% - Medical/Behavioral Review & Authorization Perform medical or behavioral review/authorization process. Ensure coverage for appropriate services within benefit and medical necessity guidelines. Assess service needs, develop and coordinate action plans, monitor services, and implement plans. Evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services. Initiate/coordinate discharge planning or alternative treatment plans as appropriate. Ensure accurate documentation of clinical information supporting medical necessity and benefits.
20% - Referrals & Compliance Utilize allocated resources to back up review determinations. Identify and make referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.). Participate in data collection/input into systems for clinical information flow and claims adjudication. Demonstrate compliance with ERISA, NCQA, URAC, DOI (State), DOL (Federal), and other regulatory requirements.
10% - Member & Provider Education Participate in direct intervention/patient education with members and providers. Serve as a member advocate through communication and education. Promote enrollment in care management or health/disease management programs. Provide telephonic support for members with chronic conditions, high-risk pregnancy, or other at-risk conditions. Conduct intensive assessments, risk-based education, and member-centered coaching using motivational interviewing techniques.
10% - Provider/Claims Coordination Maintain current knowledge of contracts and provider networks. Assist with claims information, discussions, or resolutions. Refer to appropriate internal support areas to ensure proper processing of services.
10% - Communication & Documentation Provide appropriate written and telephonic communications regarding requested services to both healthcare providers and members.
Skills & Competencies
Required Skills:
Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Strong judgment, customer service, organizational, and presentation skills. Proficiency in oral/written communication, spelling, punctuation, and grammar. Persuasion, negotiation, and influencing abilities. Analytical and critical thinking skills. Ability to handle confidential/sensitive information with discretion. Required Software & Tools:
Microsoft Office Preferred Skills:
Working knowledge of spreadsheet and database software. Knowledge of contract language and application. Thorough understanding of claims/coding analysis, requirements, and processes. Preferred Software & Tools:
Microsoft Excel, Access, or other database/spreadsheet software. Work Environment
Typical office environment. May involve work-from-home arrangements. May require some local travel within the community. Education & Experience Requirements
Required Education:
Associate Degree in Nursing
OR
Graduate of Accredited School of Nursing
OR
Master's degree in Social Work, Psychology, or Counseling. Required Experience:
2 years of clinical experience. Required Licensure/Certification:
Active, unrestricted RN license (United States and state of hire)
OR Active compact multistate unrestricted RN license (NLC)
OR Active, unrestricted LMSW license (United States and state of hire)
OR Active, unrestricted licensure as Counselor or Psychologist (United States and state of hire). Preferred Education:
Bachelor's Degree in Nursing. Preferred Experience:
7 years of healthcare program management, utilization review, or clinical experience in a specialty area (oncology, cardiology, neonatology, maternity, rehab services, mental health/chemical dependency, orthopedics, or general medicine/surgery).