Registered Nurse

Role Name: Managed Care Coordinator II/ CM-DM Location: Columbia, SC 29203 Work Environment: (Remote after 4-6 weeks of Onsite training - Travel is covered/reimbursed by the client) Contract length: 3-month assignment with possible conversion Schedule: Mon - Fri, 8:00 am - 4:30 pm. Max Pay Rate: $38/hr

In this role, you will utilize your clinical proficiency to evaluate medical necessity, coordinate action plans for members with chronic or acute illnesses, and promote cost-effective healthcare outcomes.

Responsibilities: Active Case Management:

Develop and implement member-centered action plans. Evaluate the place of service, length of stay, and medical necessity. Use motivational interviewing and reflective listening to coach members through chronic conditions, high-risk pregnancies, or acute illnesses. Clinical Review & Authorization:

Review service requests against benefit and medical necessity guidelines (NCQA/URAC). Identify and escalate referrals to Medical Directors or specialized Case Managers as needed. Member Advocacy & Education:

Provide direct intervention and education to members and providers regarding the healthcare delivery system and benefit plans. Claims & Contract Support:

Maintain expert knowledge of provider networks and contract status to assist with claims resolution and proper adjudication.

Qualifications: License:

An active, unrestricted

RN license

(SC or Compact Multistate). Education:

Associate Degree in Nursing (ADN) or a graduate of an Accredited School of Nursing. Experience:

4 years

of recent clinical experience in a defined specialty (e.g., Oncology, Cardiology, Maternity, Mental Health, Med/Surg) OR 4 years of Utilization Review/Case Management experience (with at least 2 years of direct clinical experience). Compliance:

Comprehensive knowledge of ERISA, NCQA, URAC, and Department of Insurance (DOI) guidelines.

Preferred Skills: Bachelor of Science in Nursing (BSN). Certifications:

Certified Case Manager (CCM) or clinical certification in a specialty area. 7 years

of healthcare program management experience.