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RN/Managed Care Coordinator - Remote
RN/Managed Care Coordinator - RemoteCEI • Columbia, SC, US
RN / Managed Care Coordinator - Remote

RN / Managed Care Coordinator - Remote

CEI • Columbia, SC, US
2 days ago
Job type
  • Full-time
  • Remote
Job description

Job Description

Job Description

Must have an Active Unrestricted RN License in the State of SC

Job Title : RN / Managed Care Coordinator

Location : Hybrid – Must be onsite for 1st week, then 100% Remote  | Must live within 2 hours of Columbia, SC 29229

Work Schedule / Shift : Monday–Friday, 8 : 00 AM–4 : 30 PM or 8 : 30 AM–5 : 00 PM | Minimum 40 work hours per week.

Additional Information : Equipment provided. Panel interviews conducted via Microsoft Teams.

Position Overview :

This position supports the healthcare management division, where the team is responsible for overseeing and coordinating the care needs of members through case management and telephonic support. The role was created to strengthen care coordination and ensure members receive appropriate services aligned with their medical and behavioral health needs. The team includes a variety of healthcare professionals who collaborate to manage member outcomes, support compliance with clinical guidelines, and promote cost-effective care delivery. The individual in this role will manage a dedicated caseload of members, working closely with providers and internal staff to coordinate care plans. They will serve as a key point of contact for members, supporting them with condition management, discharge planning, and education. The role requires consistent communication, documentation, and decision-making, with a focus on ensuring that members receive timely, medically necessary, and cost-effective services.

Required Skills / Experience / Qualifications :

  • Associate Degree in Nursing, or Graduate of an Accredited School of Nursing, or Master’s degree in Social Work (for Div. 6B or Div. 75), or Master’s in Psychology or Counseling (for Div. 75 only)
  • Minimum of 4 years recent clinical experience in a defined specialty area such as oncology, cardiology, neonatology, maternity, rehabilitation services, mental health / chemical dependency, orthopedic, or general medicine / surgery
  • Alternatively, 4 years of utilization review, case management, clinical, or a combination of these, with at least 2 years in clinical practice
  • Active, unrestricted RN license in the state of hire, or a compact multistate unrestricted RN license (Nurse Licensure Compact)
  • For Div. 6B roles : Active, unrestricted licensure as a social worker in the state of hire
  • For Div. 75 roles : Active, unrestricted licensure as a counselor or psychologist in the state of hire
  • For Div. 6B and Div. 75 : Ability to obtain a URAC recognized Case Management Certification within 4 years of hire
  • Working knowledge of spreadsheets and database software
  • Strong communication, active listening, and time management skills
  • Ability to work independently, prioritize effectively, and apply critical thinking
  • Must have consistent work history with limited short-term assignments

Preferred Skills (Not Required) :

  • Bachelor’s degree in Nursing
  • 7 years of healthcare program management experience
  • Case Manager certification
  • Clinical certification in specialty area
  • Telephonic care coordination and case management experience

    • Day to Day / Responsibilities :

  • Manage a caseload of members telephonically, providing care coordination, discharge planning, and triage support as needed
  • Conduct intensive assessment and evaluation of member conditions to determine care needs and next steps
  • Develop and coordinate care plans in collaboration with members, providers, and team members, ensuring alignment with service needs and goals
  • Monitor services and implement action plans, including evaluating outcomes related to eligibility, benefits, place of service, and medical necessity
  • Accurately document clinical information to support medical necessity criteria and benefit determinations
  • Provide telephonic support for members with chronic conditions, high-risk pregnancies, or other at-risk health situations
  • Deliver member-centered coaching using motivational interviewing techniques and reflective listening to drive behavior change and increase program engagement
  • Perform medical or behavioral review and authorization processes, ensuring services meet benefit and medical necessity guidelines
  • Make referrals to internal resources such as Medical Director, Preventive Services, Quality of Care, and Case Management teams as appropriate
  • Participate in data entry and system updates to maintain proper flow of clinical information and claims adjudication
  • Maintain compliance with applicable legislation and standards, including ERISA, NCQA, URAC, DOI (State), and DOL (Federal)
  • Provide education and communication to members and providers on healthcare delivery systems, utilization of networks, and benefit plans
  • Advocate for members through ongoing communication, care management program promotion, and disease management program enrollment
  • Maintain current knowledge of contracts, provider networks, and claim processes to support proper service delivery and resolution
  • Communicate determinations and updates to healthcare providers and members through written and telephonic correspondence

    • #INDGEN

    #ZR

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