Managed Care Coordinator II/CM-DM

BlueCross BlueShield of South Carolina; South Carolina; Remote; USD 10,000 - 60,000; Full time

Job summary

A leading health insurance provider is seeking a Managed Care Coordinator II to improve patient care coordination and collaborate with healthcare teams. Candidates should have extensive clinical experience and an active RN license, with a focus on patient advocacy and documentation. This is a full-time, remote position after training in South Carolina.

Benefits

Subsidized health plans

401k retirement plan with company match

Paid Time Off (PTO)

On-site cafeterias and fitness centers

Education Assistance

Qualifications

• 4 years recent clinical in defined specialty area or case management experience.
• Active, unrestricted RN license or relevant social work/counseling license required.
• Good judgment and ability to prioritize effectively.

Responsibilities

• Provide active care management and assess service needs.
• Participate in patient education and direct interventions.
• Ensure accurate documentation and clinical information flow.

Skills

Communication

Critical thinking

Customer service

Organizational skills

Education

Associates in a job-related field

Graduate of Accredited School of Nursing

Bachelor's degree in Nursing

Tools

Microsoft Office

Job description

Overview

Internal Reference Number: R1046814

We are currently hiring for a Managed Care Coordinator II to join BlueCross BlueShield of South Carolina. The professional care manager performs the primary functions of assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy. Integral to these functions is collaboration and ongoing communication with the client, the client's family or family caregiver, and other health care professionals involved in the client\'s care. Interventions focus on improving care coordination and reducing fragmentation of services, with the goal of enhancing client safety, well-being, and quality of life. Interventions consider health care costs through cost-effective and efficient care recommendations, aiming to positively impact the health care delivery system and align with the Triple Aim: improving health outcomes, enhancing the care experience, and reducing costs.

Location

This position is full-time (40 hours/week), Monday–Friday from 8:00am–4:30pm, and will be fully remote upon completion of on-site training in Columbia, SC. The candidate must reside in South Carolina.

What You\'ll Do

• Provides active care management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. Provides telephonic support for members with chronic conditions, high-risk pregnancy or other at-risk conditions, including intensive assessment/evaluation, at-risk education, and member-centered coaching using motivational interviewing and readiness-to-change assessment to elicit behavior change and increase program engagement.

• Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. Identifies, initiates, and participates in on-site reviews. Serves as member advocate through ongoing communication and education. Promotes enrollment in care management and/or health and disease management programs.

• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

• Performs medical or behavioral review/authorization processes. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Uses 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 systems for clinical information flow and proper claims adjudication. Demonstrates compliance with applicable legislation and guidelines for regulatory bodies (e.g., ERISA, NCQA, URAC, DOI, and DOL).

• 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.

Qualifications

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 job related work experience.

• Required Experience: 4 years recent clinical in defined specialty area (oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery) or 4 years utilization review/case management/clinical experience (2 of the 4 years must be clinical).

• Required Skills and Abilities: Working knowledge of word processing software; knowledge of quality improvement processes; knowledge of contract language and application; ability to work independently, prioritize effectively, and make sound decisions; good judgment; demonstrated customer service, organizational, and presentation skills; proficiency in spelling, punctuation, and grammar; strong oral and written communication; ability to persuade, negotiate, or influence others; analytical or critical thinking; ability to handle confidential information with discretion.

• Required Software and Tools: Microsoft Office.

• Required License/Certificate: An active, unrestricted RN license in the state of hire or an active compact multistate RN license (NURSE LICENSURE COMPACT) or active, unrestricted licensure as social worker (state of hire) or active, unrestricted licensure as counselor or psychologist (divisions specified). For certain divisions, URAC-certified Case Management Certification must be obtained within 4 years of hire.

Preferred Qualifications

• Preferred Education: Bachelor\'s degree in Nursing.

• Preferred Work Experience: Previous case management experience; previous experience working with health plans; 7 years healthcare program management.

• Preferred Skills and Abilities: Working knowledge of spreadsheet and database software; thorough knowledge of claims/coding analysis and processes.

• Preferred Licenses and Certificates: Case Manager certification, clinical certification in a specialty area.

Benefits

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

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. 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 providing reasonable accommodations to individuals with disabilities and pregnancy-related conditions, and to those needing accommodations for sincerely held religious beliefs, provided that accommodations do not impose undue hardship on the company. If you need special assistance or an accommodation, please email [e-mail] or call 800-288-2227, ext. 47480 with the nature of your request. We will determine accommodations 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. Some states have required notifications. More information is available upon request.