Managed Care Coordinator I (W@H Anywhere)

BlueCross BlueShield of South Carolina; United States; Remote; USD 50,000 - 75,000; Full time

Job summary

Une entreprise de premier plan dans le domaine de l'assurance santé recherche un Coordinateur de Soins Gérés I. Ce rôle implique l'évaluation des demandes de services médicaux et l'application des critères d'admissibilité en utilisant une expertise clinique, tout en travaillant de manière autonome dans un environnement entièrement à distance. Les candidates doivent posséder un diplôme d'associé et 2 ans d'expérience clinique, avec un accent particulier sur le service à la clientèle et les compétences analytiques.

Benefits

Plans de santé subventionnés

Plan d'épargne 401k avec cotisation de l'entreprise

Assurance vie

Congé payé

Assistance pour l'éducation

Qualifications

• 2 ans d'expérience clinique requise.
• Connaissance du traitement des informations médicales.
• Capacité à travailler de manière autonome.

Responsibilities

• Effectuer les évaluations d'admissibilité médicale.
• Coordonner les plans de soins et les demandes de services.
• Fournir une éducation aux patients sur les systèmes de soins de santé.

Skills

Communication

Analyse critique

Service à la clientèle

Organisation

Education

Associates dans un domaine lié

Licence RN active et sans restrictions

Tools

Microsoft Office

Job description

Managed Care Coordinator I (W@H Anywhere)

Summary

We are currently hiring for a Managed Care Coordinator I to join BlueCross BlueShield of South Carolina. In this role as a Managed Care Coordinator I, you will review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests. Utilizes clinical proficiency and claims knowledge/analysis to assess, plan, implement, 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.

Description

Location

This position is full time (40 hours/week) Monday-Friday from 8:00am – 5:00pm EST and will be fully remote.

What You’ll Do:

• Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.). Participates in data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal).
• Provides patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs.
• Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

To Qualify for This Position, You'll Need the Following:

• Required Education: Associates in a job-related field.
• Degree Equivalency: Graduate of Accredited School of Nursing or 2 years of job-related work experience.
• Required Work Experience: 2 years’ clinical experience.
• Required Skills and Abilities: Working knowledge of word processing software.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Demonstrated customer service, organizational, and presentation skills.
• Demonstrated proficiency in typing, spelling, punctuation, and grammar skills.
• Demonstrated oral and written communication skills.
• Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.
• Required Software and Tools: Microsoft Office.
• Required Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LMSW (Licensed Master of Social Work) licensure from the United States and in the state of hire, OR active, unrestricted licensure as Counselor, or Psychologist from the United States and in the state of hire.

We Prefer That You Have the Following:

• Preferred Education: Bachelor's degree- Nursing.
• Preferred Work Experience: work experience in healthcare program management, utilization review, or clinical experience in defined specialty. Specialty areas are oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery.
• Preferred Skills and Abilities: Attention to detail.
• Willingness to learn new systems and software.
• Working knowledge of spreadsheet, database software.
• Knowledge of contract language and application.
• Thorough knowledge/understanding of claims/coding analysis/requirements/processes.

Our Comprehensive Benefits Package Includes the Following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• Subsidized health plans, dental and vision coverage
• 401k retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

What To Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email [e-mail] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information .

When you hear "BlueCross BlueShield of South Carolina," you'll see people nodding in recognition. Most everyone knows who we are. As the only South Carolina-owned and operated health insurance carrier, we have been offering security to Palmetto State citizens for more than 70 years. We are also one of South Carolina's largest employers.

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