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Managed Care Coordinator II/CM-DM
2 weeks ago
Spectraforce Technologies West Columbia, United StatesJob Title: Managed Care Coordinator II · Location: Columbia, SC Remote after 1 week onsite training. Have to come in periodically for meetings/classes as needed) · Duration: 3 months assignment with possible extensions · Shift: Mon-Fri, 8:30 am - 5pm. · Payrate $34.60/hr. · Summa ...
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Managed Care Coordinator UM II
1 day ago
Spectraforce Technologies West Columbia, United StatesJob Title: Managed Care Coordinator UM II · Location: Columbia, SC Remote, after onsite training) · Duration: 4 months assignment with possible conversion · Shift:40hrs/week · Payrate: $34/hr. · Summary: · Reviews and evaluates medical or behavioral eligibility regarding benefits ...
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Prisma Health Columbia, United States Full timeInspire health. Serve with compassion. Be the difference. · Job Summary · Provides direct and indirect counseling services to patients and their families using individual, group, and family therapy. Provides bio-psychosocial assessments, risk assessments, treatment planning and ...
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Ambulatory Care Nurse II
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Customer Care Manager II
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Care Coordinator II
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Patient Care Coordinator II
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Care Coordinator I or II
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Care Coordinator II
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Care Coordinator I or II
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Global Services Patient Care Coordinator II
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global services patient care coordinator ii
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Children's National Medical Center Washington, DC , USA, United StatesThe Patient Care Coordinator, Global Services (PCC) is responsible for providing high-level care coordination to international patients and families, referring sponsors, and internal clients. This role is responsible for providing efficient, individualized services to Global Serv ...
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MDS Coordinator
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MSIPP-EM Post Doc Research Associate
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Registered Nurse
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Patient Care Tech
1 week ago
Medical University of South Carolina Columbia, United States Full timeJob Description · The Patient Care Technician II (PCT II) at the Medical University of South Carolina (MUSC) provides advanced patient care under the direction of registered nurses and healthcare professionals. The PCT II is responsible for assisting with direct patient care, mo ...
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Mental Health Professional I
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Licensed Practical Nurse
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Registered Nurse
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Certified Surgical Technologist II
2 weeks ago
Medical University of South Carolina Columbia, United States Full timeDay (United States of America) Job Description · Job summary: Under the supervision of the Nurse Manager, the Certified Surgical Tech follows established procedural guides in the preparation of sterile supplies and equipment used in the surgical procedures, performs appropria ...
coordinator, managed care ii/cm-dm - Columbia, SC , USA, United States - LanceSoft Inc
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, claims knowledge/analysis, and comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness.
Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals.
Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.Provides telephonic support for members with chronic conditions, high risk pregnancy or other at risk conditions thatconsist 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.
20% Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. 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 isnot limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal).
Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.
Promotes enrollment in care management programs and/or health and disease management programs.
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.
Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.Required Skills and Abilities:
Working knowledge of word processing software. Knowledge of quality improvement processes and demonstrated ability with these activities. Knowledge of contract language and application. 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. Thorough knowledge/understanding of claims/coding analysis, requirements, and 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 form one's/out of one's home. May involve some travel within one's community.
