Location
Charleston, SC | United States
Job description
Description:
- Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions.
- Utilizes clinical proficiency and claims knowledge/analysis to assess, plan, implement, health coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, options, and services required to support members in managing their health, chronic illness, or acute illness.
- Utilizes available resources to promote quality, cost effective outcomes.
- 50% Performs medical or behavioral review/authorization process.
- Ensures coverage for appropriate services within benefit and medical necessity guidelines.
- Assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans.
- Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
- May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate.
- Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
- 20% Utilizes allocated resources to back up review determinations.
- Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.).
- Participates in data collection/input into system for clinical information flow and proper claims adjudication.
- Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal).
- 10% Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.
- Serves as member advocate through continued communication and education.
- Promotes enrollment in care management programs and/or health and disease management programs.
- Provides telephonic support for members with chronic conditions, high-risk pregnancy or other at-risk conditions that consist of: intensive assessment/evaluation of the condition, at-risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement.
- 10% Maintains current knowledge of contracts and network status of all service providers and applies appropriately.
- Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.
- 10% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
Skills & Qualifications: - Utilization management experience and /or Appeals experience /strong clinical skills, Behavioral Health, or infusion therapy experience
- Case management experience is a PLUS
- Bachelor degree in Nursing REQUIRED
- Previous Medicare experience is a PLUS
- Ability to process authorization requests in timely fashion
- MUST have strong verbal and written communication skills
- Strong medical terminology knowledge
- MUST be comfortable speaking on the phone
Experience Level: Intermediate Level
About Actalent Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
Diversity, Equity & Inclusion At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:
- Hiring diverse talent
- Maintaining an inclusive environment through persistent self-reflection
- Building a culture of care, engagement, and recognition with clear outcomes
- Ensuring growth opportunities for our people
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email
[email protected] for other accommodation options.
Job tags
Salary