Job Information
ManpowerGroup Coordinator, Managed Care I in Columbia, South Carolina
Title: Coordinator, Managed Care I
Location: 4101 Percival Road Columbia SC 29229 US (Hybrid)
Duration: 04+ Contract
Pay Range $25.00 to $30.00/hr.
Schedule: Full-time, 40 hrs/week (Monday - Friday, 8:30 AM - 5:00 PM)
We are looking for a “Coordinator, Managed Care I” to join one of our Fortune 500 clients.
Job Summary
The Clinical Review Specialist assesses and evaluates medical or behavioral eligibility for health benefits, ensuring services meet clinical and administrative standards. This role requires the application of clinical expertise, administrative policies, and established criteria to evaluate service requests, manage health interventions, and ensure members receive quality, cost-effective care. The Clinical Review Specialist will review medical necessity, support care management plans, and guide members toward better health outcomes.
Key Responsibilities:
Medical/Behavioral Review (50%):
Perform medical or behavioral review and authorization processes.
Ensure coverage aligns with benefit and medical necessity guidelines.
Develop and coordinate action plans, in collaboration with members, to monitor services and implement treatment plans.
Evaluate outcomes related to eligibility, benefits, service type, length of stay, and medical necessity.
Initiate or coordinate discharge planning and alternative treatment as needed.
Accurately document clinical information to support medical necessity and contract benefits.
Resource Utilization and Referral (20%):
Use allocated resources to back up review determinations.
Identify and refer cases to appropriate internal departments (e.g., Medical Director, Case Manager, Quality of Care Referrals).
Participate in data collection and input clinical information for claims adjudication.
Ensure compliance with regulatory guidelines (e.g., ERISA, NCQA, URAC, DOI, DOL).
Member and Provider Education (10%):
Provide direct intervention and education regarding healthcare delivery, utilization, and benefit plans.
Act as an advocate, promoting enrollment in care and disease management programs.
Provide telephonic support for members with chronic or high-risk conditions, utilizing motivational interviewing techniques to support behavior change.
Contract and Claims Knowledge (10%):
Maintain knowledge of contract and network status for all providers.
Assist with claims information, discussion, and resolution, ensuring proper processing of services.
Communication and Documentation (10%):
Provide clear communication to both providers and members regarding service requests.
Document all actions accurately in support of medical necessity and benefits coverage.
Required Skills and Abilities:
Proficiency in word processing software and Microsoft Office.
Ability to work independently, prioritize effectively, and make sound decisions.
Excellent judgment, customer service, organizational, and presentation skills.
Strong oral and written communication skills, with proficiency in spelling, punctuation, and grammar.
Skills in persuasion, negotiation, and influence.
Analytical and critical thinking skills.
Ability to handle confidential information with discretion.
Preferred Skills:
Familiarity with spreadsheets and databases (e.g., Microsoft Excel, Access).
Knowledge of contract language, claims/coding analysis, and related processes.
Educational Requirements:
Required: Associate Degree in Nursing, Graduate of Accredited Nursing Program, or Master’s Degree in Social Work, Psychology, or Counseling.
Preferred: Bachelor’s Degree in Nursing.
Licensure and Certification:
Active, unrestricted RN license or LMSW license, or licensure as Counselor or Psychologist in the state of hire.
Compact multistate unrestricted RN license (if applicable).
Experience:
Required: Minimum 2 years of clinical experience.
Preferred: 7 years in healthcare program management, utilization review, or clinical experience in specialties such as oncology, cardiology, neonatology, maternity, rehab services, mental health, chemical dependency, orthopedics, or general medicine/surgery.
Interview process :
01 round of interview
We are looking for the candidate who are eligible to collaborate with any employers without sponsorship .
If you are interested, please click “Apply” button.
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ManpowerGroup is committed to providing equal employment opportunities in a professional, high quality work environment. It is the policy of ManpowerGroup and all of its subsidiaries to recruit, train, promote, transfer, pay and take all employment actions without regard to an employee's race, color, national origin, ancestry, sex, sexual orientation, gender identity, genetic information, religion, age, disability, protected veteran status, or any other basis protected by applicable law.