CEI · 1 month ago
RN/Managed Care Coordinator - Remote
United States
Full-time
Remote
Mid, Senior Level
$30/hr - $30/hr
4+ years expCEI is a healthcare company seeking a Managed Care Coordinator/RN to provide telephonic case management for members. The role involves coordinating care with providers, patients, and internal teams while ensuring compliance with healthcare guidelines.
Information TechnologyIT ManagementMechanical EngineeringSoftware
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 or provide health management program interventions
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
Promote quality, cost-effective outcomes by leveraging available resources
Provide active case management: assess service needs, develop and coordinate action plans with members, monitor services, and implement plans to include member goals. Evaluate outcomes, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions
Ensure accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits
Deliver telephonic support for members with chronic conditions, high-risk pregnancy, or other at-risk conditions, including intensive assessment, education, and member-centered coaching using motivational interviewing techniques
Perform medical or behavioral review/authorization processes, ensuring coverage for appropriate services within benefit and medical necessity guidelines
Identify and make referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, etc.)
Participate in data collection/input for clinical information flow and proper claims adjudication
Demonstrate compliance with all applicable legislation and guidelines (ERISA, NCQA, URAC, DOI, DOL)
Engage in direct intervention/patient education with members and providers regarding healthcare delivery systems, utilization of networks, and benefit plans
Maintain current knowledge of contracts and network status of all service providers and assist with claims information and resolution
Provide appropriate communications (written and telephone) regarding requested services to both healthcare providers and members
Qualification
Required
Education: Associate Degree in Nursing OR Graduate of Accredited School of Nursing OR Master's in Social Work (Div. 6B or Div. 75) OR Master's in Psychology or Counseling (Div. 75 only)
Experience: Minimum 4 years recent clinical experience in specialty areas (oncology, cardiology, maternity, mental health, etc.) OR 4 years in utilization review/case management/clinical (2 years must be clinical)
Licensure: Active, unrestricted RN license (state of hire or compact multistate) OR active, unrestricted license as social worker, counselor, or psychologist (as applicable)
Certification: URAC-recognized Case Management Certification within 4 years of hire (Div. 75 & Div. 6B)
Preferred
Bachelor's degree in Nursing
7 years healthcare program management experience
Case Manager certification and/or clinical specialty certification
Company
CEI
CEI is at the forefront of providing software solutions for pressure vessel design and welding procedure management, being the first company to offer a solution for ASME Section VIII and Section IX over 30 years ago.
11-50 employees
Funding
Current Stage
Early StageLeadership Team
Michael Hartnett
CEO
Amee Hamilton
Chief Technology Officer
Company data provided by crunchbase