Managed Care Coordinator I

About This Role

The Managed Care Coordinator I evaluates medical or behavioral eligibility for services, applying clinical expertise to approve requests and coordinate care plans for members. This role ensures appropriate utilization of resources to promote quality, cost-effective healthcare outcomes.

Responsibilities

• Perform medical or behavioral review/authorization process, ensuring coverage for appropriate services within benefit and medical necessity guidelines
• Evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions
• Initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate
• Ensure accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits
• Utilize allocated resources to back up review determinations and make referrals to appropriate staff
• Participate in data collection/input into system for clinical information flow and proper claims adjudication
• Demonstrate compliance with all applicable legislation and guidelines for regulatory bodies
• Provide patient education to members and providers regarding health care delivery system, networks, and benefit plans
• Maintain current knowledge of contracts and network status of all service providers and apply appropriately
• Assist with claims information, discussion, and/or resolution and refer to appropriate internal support areas

Requirements

• 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 typing, 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
• Microsoft Office

Qualifications

• Associates in a job-related field or Graduate of Accredited School of Nursing
• 2 years' clinical experience or 2 years' job-related work experience (if no nursing degree)

Nice to Have

• Work experience in healthcare program management, utilization review, or clinical experience in defined specialty
• Keen attention to detail
• Willingness to learn new systems and software
• Working knowledge of spreadsheet, database software
• Knowledge of contract language and application
• Thorough knowledge/understanding of claims/coding analysis/requirements/processes

Skills

* Required skills

Benefits