Title: Coordinator, Managed Care I
Address: Columbia, SC 29229
Duration: 3 months
Rate range: $25 to $30
Position Overview
The Utilization Review Nurse performs medical or behavioral eligibility reviews to determine benefits and clinical criteria compliance. By leveraging clinical expertise, administrative policies, and established criteria, the nurse evaluates service requests, supports members in managing their health conditions, and ensures optimal outcomes through cost-effective interventions.
Key Responsibilities

• Medical/Behavioral Review & Authorization (50%)
  • Conduct medical necessity and benefit eligibility reviews for requested services.
  • Assess service needs, develop coordinated action plans, and monitor outcomes.
  • Document clinical information accurately to support determinations.
  • Initiate and coordinate discharge planning or alternative treatment plans when necessary.
• Resource Management & Referrals (20%)
  • Utilize allocated resources to support review determinations.
  • Refer cases to appropriate staff, such as Medical Directors, Case Managers, or Quality of Care teams.
  • Ensure compliance with ERISA, NCQA, URAC, DOI, DOL, and other applicable regulations.
• Patient Education & Support (10%)
  • Provide direct intervention and education to members and providers regarding health care delivery systems and benefit plans.
  • Encourage enrollment in care management or disease management programs.
  • Offer telephonic support for members with chronic conditions or high-risk pregnancies, including assessments, education, and coaching for behavior change.
• Claims & Provider Communication (10%)
  • Maintain knowledge of contracts and network statuses for service providers.
  • Assist with claims discussions and refer to internal support for resolution.
• Team Collaboration (10%)
  • Foster communication between healthcare providers, members, and internal teams.
  • Assist with queue management and provide support to team members as needed.

Qualifications

• Required Skills & Experience
  • Active RN license.
  • Minimum of 2 years of hospital experience.
  • Utilization review experience is highly preferred.
  • Strong clinical expertise with familiarity in claims processes and medical necessity criteria.
• Soft Skills
  • Clear and concise documentation.
  • Strong organizational abilities.
  • Ability to work autonomously.
  • Adaptable and flexible with a willingness to support others.
  • Exceptional team player with strong communication skills.
• Preferred Skills
  • Experience in various areas of work within healthcare.
  • Background in case management or concurrent reviews.

Work Environment & Schedule

• Schedule : Monday-Friday, 8:30 AM-5:00 PM.
• Location : Initial onsite training for one week; remote work thereafter. Candidates must live within a 2-hour radius of the client location.
• Compensation : Up to $30/hour.

Team Dynamics
The team is a close-knit group experienced in precertifying outpatient procedures for office and hospital settings. Collaboration is essential, as the role involves working closely with concurrent nurses, case management, medical directors, providers, and members.
Interview Process
Candidates will participate in Microsoft Teams interviews with the hiring manager.
What We're Not Looking For

• No hospital experience.
• Frequent job hopping.
• Candidates without an RN license.