Registered Nurse

Role Name: Managed Care Coordinator II/ CM-DM

Location: Columbia, SC 29203

Work Environment: (Remote after 4-6 weeks of Onsite training - Travel is covered/reimbursed by the client)

Contract length: 3-month assignment with possible conversion

Schedule: Mon - Fri, 8:00 am - 4:30 pm.

Max Pay Rate: $38/hr

In this role, you will utilize your clinical proficiency to evaluate medical necessity, coordinate action plans for members with chronic or acute illnesses, and promote cost-effective healthcare outcomes.

Responsibilities:

• Active Case Management: Develop and implement member-centered action plans. Evaluate the place of service, length of stay, and medical necessity. Use motivational interviewing and reflective listening to coach members through chronic conditions, high-risk pregnancies, or acute illnesses.
• Clinical Review & Authorization: Review service requests against benefit and medical necessity guidelines (NCQA/URAC). Identify and escalate referrals to Medical Directors or specialized Case Managers as needed.
• Member Advocacy & Education: Provide direct intervention and education to members and providers regarding the healthcare delivery system and benefit plans.
• Claims & Contract Support: Maintain expert knowledge of provider networks and contract status to assist with claims resolution and proper adjudication.

Qualifications:

• License: An active, unrestricted RN license (SC or Compact Multistate).
• Education: Associate Degree in Nursing (ADN) or a graduate of an Accredited School of Nursing.
• Experience: 4 years of recent clinical experience in a defined specialty (e.g., Oncology, Cardiology, Maternity, Mental Health, Med/Surg) OR 4 years of Utilization Review/Case Management experience (with at least 2 years of direct clinical experience).
• Compliance: Comprehensive knowledge of ERISA, NCQA, URAC, and Department of Insurance (DOI) guidelines.

Preferred Skills:

• Bachelor of Science in Nursing (BSN).
• Certifications: Certified Case Manager (CCM) or clinical certification in a specialty area.
• 7 years of healthcare program management experience.