Medical Management Coordinator (Remote)

Position Summary

The Medical Management Coordinator coordinates all utilization management, and case management activities for the Spartanburg Regional Healthcare System group. The position provides support function to the RHP Medical Management Committee. Must meet productivity standards, complete work in a timely manner. Must be flexible and adapt to changes in the work environment; manage competing demands; change the approach or method to best fit the situation; be able to cope with delay or unexpected events. Take responsibility; keep commitments; complete tasks on time. Volunteer readily; take independent actions; ask for and offer help when needed.

* Only Applicants from the following states: Alabama, Arizona, Connecticut, Delaware, Florida, Georgia, Indiana, Kansas, Kentucky, Louisiana, Maryland, Michigan, North Carolina, Pennsylvania, Rhode Island, South Carolina, Virginia, West Virginia, Wisconsin.

Minimum Requirements

Education           

• Registered Nurse

Experience        

• 5 years clinical experience
• 3 years Utilization Management or Case Management Experience

License/Registration/Certifications       

• Valid Driver’s license with good driving record

Core Job Responsibilities

• Responsible for the delegated Utilization Review activities for SRHS Health Plan, and others as needed.
• Coordinates outpatient service review, precertification review, and certification review activities.
• Review all incoming clinical for outpatient service precertification using specified criteria.
• Facilitate discussions with RHP Medical Director of cases that require clinical review related to active cases, extended length of stay, catastrophic cases, difficult discharge dispositions, and appropriate levels of care. Refer any cases to external specialist for review when needed.
• Performs subsequent reviews based on criteria guidelines.
• Communicates daily with outside facilities/providers results of requested review. Displays appropriate communicates avenues with facilities, case managers and DCP’s.
• Maintains documents and service in a manner that achieves and maintains member confidentiality and is consistent with HIPAA guidelines.
• Maintain and update data bases logging Medical Director Reviews, Appeal and statistics in compliance with URAC standards.
• Research and review any claims issues related to utilization management and / or medical necessity from Third Party Administrator. Communicate results of review to Third Party Administrator.
• Maintain and update data bases logging Medical Director Reviews, Appeal and statistics in compliance with URAC standards.
• Professionally manages member/customer requests and complaints. Seeks to resolve customer complaints and problems. Provides information regarding the appeal process to members as requested, and serves as a resource to members, providers, and RHP.
• Provide notification to Stop Loss carrier and Third-Party Administrator of any plan participant with potential high dollar claims based on medical reviews.
• Provide clinical updates as requested
• Work w/ Plan Administrators on unique cases that may require special considerations/exceptions to provide a sound quality and fiscal outcome.
• Meets with appropriate physicians and other providers  to gain physician understanding and support for the CarePlus Medical Management Utilization Management Process.
• Negotiates rate with any out-of-network services as needed.
• Identify potential care management cases through readmissions, emergency room utilization, catastrophic diseases, high dollar treatments, and/or referrals from other CarePlus team members.
• Determine any appropriate referrals to other CarePlus team members, not limited to, Transitional Care Program, Disease Management Program, Health Coach, or Community Programs.
• All documents and data are timely, complete, and accurate.
• Performs all duties within a timely manner.
• All other duties as assigned.