TALENT Software Services · 4 weeks ago
Managed Care Coordinator UM
Columbia, SC
Contract
Onsite
Mid Level
$30/hr - $34/hrTALENT Software Services is seeking an experienced Managed Care Coordinator UM to join their dynamic team in Columbia, SC, where they can make a meaningful impact on members' health and well-being. The role focuses on providing quality care and ensuring cost-effective outcomes by reviewing and evaluating medical eligibility and coordinating services for members.
Artificial Intelligence (AI)ConsultingDevOpsHealth CareIT ManagementProject ManagementRecruitingStaffing Agency
Responsibilities
Review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests
Utilize clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of the 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
Perform medical or behavioral review/authorization processes and ensure coverage for appropriate services within benefit and medical necessity guidelines
Participate in data collection/input into the system for clinical information flow and proper claims adjudication
Provide discharge planning and assess service needs in cooperation with providers and facilities
Provide appropriate communications (written, telephone) regarding requested services to both healthcare providers and members
Participate in direct intervention/patient education with members and providers regarding the healthcare delivery system, utilization on networks, and benefit plans
Maintain current knowledge of contracts and network status of all service providers and apply appropriately
Process prior authorization requests for the Medicare Advantage line of business
Review and apply Medicare criteria to authorization requests
Process appeals requests
Work in Utilization Management or Appeals workflows
Collaborate with team members to ensure the timely movement of authorization requests
Utilize multiple applications to process authorizations and appeals
Qualification
Required
Microsoft Office
Preferred
Working knowledge of spreadsheet, database software, claims/coding analysis, requirements, and processes
Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software
Utilisation Management (UM) experience
Appeals processing experience
Strong clinical skills
Behavioural Health or infusion therapy experience
Strong ability to process authorization requests accurately and timely
Excellent written clinical documentation skills
Effective verbal and written communication
Ability to collaborate with team members to move work efficiently
Adaptable and able to perform in a fast-paced environment
Company
TALENT Software Services
Talent Software Services is an IT staffing services company of healthcare and government sectors.
Founded in 1987
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Prashanth Upadrashta
Vice President -Global Operations & Delivery
Dave Iacarella
Owner
Recent News
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