Care Coordinator

• Review and evaluate medical or behavioral eligibility, benefits, and clinical criteria for service requests
• Apply clinical expertise, administrative policies, and established clinical criteria to utilization management decisions
• Assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and required services
• Promote quality and cost-effective outcomes using available resources
• Perform medical or behavioral review and authorization processes
• Ensure coverage for appropriate services within benefit and medical necessity guidelines
• Make referrals to Medical Directors, Case Managers, Preventive Services, Subrogation, Quality of Care Referrals, and other appropriate staff
• Collect and input data for clinical information flow and claims adjudication
• Maintain compliance with applicable legislation and regulatory guidelines
• Provide discharge planning and assess service needs with providers and facilities
• Evaluate care-plan outcomes, eligibility, benefits, place of service, length of stay, medical necessity, and benefit exceptions
• Document clinical information supporting medical necessity criteria and contract benefits
• Collaborate with Care Management and other areas to execute care management processes timely
• Manage assigned members and authorizations through appropriate communication
• Communicate with healthcare providers and members by phone and in writing
• Participate in direct intervention and patient education regarding healthcare delivery systems, networks, and benefit plans
• Identify, initiate, and participate in on-site reviews when appropriate
• Promote enrollment in care management and health/disease management programs
• Maintain current knowledge of contracts and provider network status
• Assist with claims information, discussion, and resolution; refer issues to internal support areas

RN Managed Care Coordinator II – UM

• Ensure the success and stability of foster placements by supporting youth and caregivers
• Increase visibility and awareness of the foster care program
• Assist with administrative tasks
• Engage in marketing and outreach efforts
• Enhance the program’s social media presence
• Conduct home visits
• Provide case management and support to foster families
• Coordinate services
• Manage documentation and compliance tasks
• Collaborate with internal staff and community partners
• Develop content or materials for outreach
• Engage with the community to recruit and support new foster homes
• Provide emergency or urgent support for foster families through the on-call weekend rotation

Care Coordinator jobs in South Carolina

RN Managed Care Coordinator II – UM

Foster Care Coordinator