Location
Columbia, South Carolina
Job Type
Full-time
Posted
May 16, 2026
Job Description
Duties:
- Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions. Utilizes clinical proficiency and claims knowledge/analysis to assess, plan, implement, health coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective outcomes.
- 50% Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans. Evaluates outcomes of plan...
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