Case Coordinator

• Provide active care management and assess members’ service needs
• Develop, coordinate, monitor, and evaluate member-centered action plans
• Assess eligibility, benefit levels, place of service, length of stay, medical necessity, and benefit exceptions
• Document clinical information supporting medical necessity and contract benefits
• Provide telephonic support for members with chronic conditions, high-risk pregnancy, and other at-risk conditions
• Deliver condition-specific education and member-centered coaching using motivational interviewing, reflective listening, and readiness-to-change assessment
• Educate and intervene directly with members and providers regarding health care delivery, networks, and benefit plans
• Identify, initiate, and participate in on-site reviews
• Advocate for members through continued communication and education
• Promote enrollment in care management and health and disease management programs
• Communicate requested-service information to health care providers and members in writing and by telephone
• Perform medical or behavioral review and authorization processes
• Ensure service coverage complies with benefit and medical necessity guidelines
• Make referrals to Medical Directors, Case Managers, Preventive Services, Subrogation, and Quality of Care teams
• Collect and input clinical information for proper claims adjudication
• Comply with ERISA, NCQA, URAC, DOI, DOL, and other applicable regulations
• Maintain current knowledge of contracts and provider network status
• Assist with claims information, discussion, and resolution; refer issues to internal support areas

Case Coordinator jobs in South Carolina

Case Management Coordinator, Maternity Focus