Managed Care Coordinator II/CM-DM (Pediatric Oncology- Must reside in South Carolina)

BlueCross BlueShield of South Carolina; Columbia (SC); Remote; USD 50,000 - 80,000; Full time

Job summary

An established industry player is seeking a Managed Care Coordinator II to enhance care coordination and improve client outcomes. This full-time remote position emphasizes care management interventions, ensuring effective communication with clients and healthcare providers. The role involves assessing needs, developing action plans, and advocating for members while navigating healthcare regulations. Join a diverse and community-focused team that values innovation and offers comprehensive benefits, including health coverage and a 401K plan. If you're passionate about making a difference in healthcare, this opportunity is perfect for you.

Benefits

Health Coverage

Dental Coverage

Vision Coverage

401K with Company Match

Life Insurance

PTO

Education Assistance

Qualifications

• Associates degree or equivalent work experience required.
• Active RN license or equivalent licensure needed.

Responsibilities

• Provide active care management and assess client needs.
• Advocate for members and support chronic condition management.

Skills

Care Management

Communication Skills

Customer Service

Organizational Skills

Clinical Assessment

Education

Associates Degree

Bachelor's Degree in Nursing

Tools

Word Processing Software

Spreadsheets

Databases

Job description

Summary

We are currently hiring for a Managed Care Coordinator II/CM-DM to join BlueCross BlueShield of South Carolina. This role focuses on care management interventions to improve care coordination and reduce fragmentation among multiple healthcare providers and settings, aiming to enhance client safety, well-being, and quality of life. The care manager performs assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy, collaborating closely with clients, families, and healthcare professionals.

Why join BlueCross BlueShield of South Carolina?

With over seven decades of community roots, we are the largest insurance provider in South Carolina, a leading administrator of government contracts, and operate a sophisticated data center. We offer a diverse, innovative, and community-focused environment.

Job Description

Logistics:

This is a full-time (40 hours/week), remote position (W@H) based in South Carolina.

Responsibilities:

1. Provide active care management, assess needs, develop and coordinate action plans, monitor services, and evaluate outcomes.
2. Ensure accurate documentation supporting medical necessity and benefits.
3. Support members with chronic conditions through telephonic assessments, education, and coaching.
4. Participate in member and provider education regarding healthcare delivery and utilization.
5. Identify and participate in on-site reviews as needed.
6. Advocate for members through communication and education.
7. Promote enrollment in care management and health programs.
8. Communicate effectively with providers and members regarding services.
9. Perform review and authorization processes within coverage guidelines.
10. Utilize resources to support review decisions.
11. Refer to appropriate staff for specialized needs.
12. Contribute to data collection and system input for clinical and claims processing.
13. Comply with all relevant legislation and guidelines (e.g., ERISA, NCQA, URAC).
14. Maintain knowledge of provider contracts and network status.
15. Assist with claims discussions and resolution.

Qualifications:

• Associates degree in a related field or equivalent work experience.
• Recent clinical experience in a specialty area (e.g., oncology, cardiology, mental health).
• Knowledge of word processing, quality improvement, contract language, and healthcare regulations.
• Ability to work independently, prioritize, and make sound decisions.
• Strong customer service, communication, and organizational skills.
• Active, unrestricted RN license or equivalent licensure (social worker, counselor, psychologist).
• Case management certification within four years if applicable.

Preferred Qualifications:

• Bachelor's degree in Nursing or related field.
• Pediatric oncology experience.
• Knowledge of spreadsheets, databases, and claims/coding analysis.
• Additional certifications in case management or clinical specialties.

Benefits:

• Health, dental, and vision coverage.
• 401K with company match.
• Life insurance, PTO, education assistance, and more.

Our Commitment:

We value diversity and inclusion, providing equal employment opportunities and accommodations for individuals with disabilities or religious needs. For assistance, contact [e-mail] or call 800-288-2227, ext. 47480.

EEO Statement:

We are an Equal Opportunity Employer, participating in E-Verify and complying with all applicable laws and regulations.