Managed Care Coordinator II, CM-DM

BlueCross BlueShield of South Carolina; South Carolina; Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization seeks a Managed Care Coordinator II to enhance care coordination and improve health outcomes. The role involves active management of chronic conditions, collaboration with healthcare providers, and effective communication with members. This full-time remote position offers a chance to impact client safety and quality of life while navigating healthcare costs.

Benefits

Health Insurance

Dental Insurance

Vision Plans

401k with Match

Life Insurance

PTO

Qualifications

• 4 years of clinical experience in a specialty area or utilization review/case management.
• Active, unrestricted RN license or equivalent licensure.

Responsibilities

• Provide active care management, assess service needs, and develop action plans.
• Communicate effectively with healthcare providers and members regarding services.

Skills

Clinical Experience

Communication

Advocacy

Education

Associate's Degree

Bachelor's Degree in Nursing

Tools

Microsoft Office

Job description

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Summary

Care management interventions focus on improving care coordination and reducing the fragmentation of services recipients often experience, especially when multiple healthcare providers and settings are involved. These interventions aim to enhance client safety, well-being, and quality of life, while considering healthcare costs through cost-effective and efficient care recommendations. Effective care management positively impacts the healthcare system by helping achieve the "Triple Aim": improving health outcomes, enhancing the healthcare experience, and reducing costs. The care manager performs assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy, working collaboratively with clients, families, and healthcare professionals.

Position Details

This is a full-time (40 hours/week) remote position, Monday-Friday, 8:30 am-5:00 pm.

Responsibilities

1. Provide active care management, assess service needs, develop and coordinate action plans, monitor services, and evaluate outcomes. Ensure documentation supports medical necessity and benefits. Support members with chronic or high-risk conditions through telephonic assessments, education, and coaching.
2. Participate in direct interventions and patient education regarding healthcare delivery, utilization, and benefits. Identify and participate in reviews. Advocate for members through communication and education. Promote enrollment in management programs.
3. Communicate effectively with healthcare providers and members regarding services and coverage.
4. Perform medical or behavioral reviews, ensure coverage within guidelines, utilize resources for review determinations, and refer to appropriate staff. Contribute to data collection for clinical and claims processing. Comply with all relevant legislation and guidelines.
5. Maintain current knowledge of contracts and network status. Assist with claims discussions and resolution.

Qualifications

• Associate's degree in a related field or equivalent experience.
• 4 years of clinical experience in a specialty area or 4 years of utilization review/case management, with at least 2 years clinical.
• Proficiency in Microsoft Office and knowledge of quality improvement processes.
• Active, unrestricted RN license or equivalent licensure as specified.

Preferred Qualifications

• Bachelor's degree in Nursing or related field.
• 7+ years in healthcare program management.
• Additional certifications such as Case Manager certification.

Benefits

• Health, dental, vision plans, 401k with match, life insurance, PTO, and more.

Equal Opportunity Statement

BlueCross BlueShield of South Carolina is an equal opportunity employer committed to diversity and inclusion. We provide reasonable accommodations for individuals with disabilities or religious needs. For assistance, contact [e-mail] or call 800-288-2227, ext. 47480.