Managed Care Coordinator II/CM - Social Worker

BlueCross BlueShield of South Carolina; United States; Remote; USD 53,000 - 103,000; Full time

Job summary

Join a leading health care provider as a Managed Care Coordinator II. This fully remote position focuses on care management interventions, enhancing client safety and coordinating services for members with chronic conditions. You will engage in assessments, planning, and advocacy, making a meaningful impact on their health care experiences.

Benefits

Subsidized health plans, dental and vision coverage

401k retirement savings plan with company match

Paid Time Off (PTO)

Education Assistance

Qualifications

• Required education: Associates or higher in a job-related field.
• Experience: Four years clinical or case management experience required.
• Licenses: RN license or social worker license in state of hire.

Responsibilities

• Provides active care management and assesses service needs.
• Engages in telephonic support for members with chronic conditions.
• Performs medical review/authorization processes and ensures compliance.

Skills

Customer Service

Analytical Skills

Organizational Skills

Communication

Education

Associates in a job-related field

Bachelor's degree in health-related field

Tools

Microsoft Office

Job description

Managed Care Coordinator II/CM - Social Worker

Summary

We are currently hiring for a Managed Care Coordinator II to join BlueCross BlueShield of South Carolina. We provide care management services to more than 2 million members in South Carolina and nationally.

Summary

We are currently hiring for a Managed Care Coordinator II to join BlueCross BlueShield of South Carolina. We provide care management services to more than 2 million members in South Carolina and nationally.

Position Purpose: Care management interventions focus on improving care coordination and reducing the fragmentation of the services the recipients of care often experience, especially when multiple health care providers and different care settings are involved. Taken collectively, care management interventions are intended to enhance client safety, well-being, and quality of life. These interventions carefully consider health care costs through the professional care manager's recommendations of cost-effective and efficient alternatives for care. Thus, effective care management directly and positively impacts the health care delivery system, especially in realizing the goals of the "Triple Aim," which include improving the health outcomes of individuals and populations, enhancing the experience of health care, and reducing the cost of care. 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, client's family or family caregiver, and other health care professionals involved in the client's care.

The position will be working from home on a desktop computer to provide highly interactive case management to assigned members. Members will include those with chronic or high-risk conditions and those who are admitted to inpatient care. Educating and guiding members through prior authorizations and understanding the need to adhere to medications and the plan of care. Most interactions will be by phone and through our messaging system. Perfect for those who love case management and improving the lives and medical outcomes of members while working in your own home office.

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Having over 15,000 employees across the country opens a lot of career opportunities. You can move up within your line of business or move to another one of our lines of business. You retain your tenure and benefits while growing your career in a different area. This is not possible at most smaller organizations. We also offer a generous education reimbursement program to prepare you for future career growth.

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

Description

Logistics: About Us | BlueCross BlueShield of South Carolina

Location: This position is full time (40 hours/week) Monday-Friday and will be fully remote (Work at Home). To work from home, you must have high-speed (non-satellite) internet and a private, secure home office.

What You’ll Do:

• Provides active care management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors service 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 that consist of intensive assessment/evaluation of condition, at-risk education based on members identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement.

• Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. May identify, initiate, and participate in on-site reviews. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs 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 process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. 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).

• 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.

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: Four years recent clinical in defined specialty area. Specialty areas include oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery. OR, four years utilization review/case management/clinical/or combination; two of the four years must be clinical.

• Required Skills and Abilities: Working knowledge of word processing software. Knowledge of quality improvement processes and demonstrated ability with these activities. Knowledge of contract language and application. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in 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: An active, unrestricted RN license 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 licensure as social worker from the United States and in the state of hire (in Div. 6B) OR, active, unrestricted licensure as counselor, or psychologist from the United States and in the state of hire (in Div. 75 only). For Div. 75 and Div. 6B, except for CC 426: URAC recognized Case Management Certification must be obtained within four years of hire as a Case Manager.

We Prefer That You Have the Following:

• Education: Bachelor's degree in health-related field (Nursing, Healthcare Administration, Pharmacy, Sciences, Applied Health)

• Work Experience: Stable work history in case management, strongly preferred. Five years of experience in case management. Prior work from home experience is a plus.

• Skills and Abilities: Strong communication and customer services skills. Excellent analytical skills to problem solve and remedy issues immediately. Ability to work in an autonomous environment or leadership capacity.

• Software and Tools: Working knowledge of Microsoft Word, PowerPoint, Excel, or other spreadsheet/database software; TMCS, LiveOps, MDDS, and BlueVue.

• Licenses and Certificates: Case manager certification, clinical certification in specialty area. Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS) certification.

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.

Pay Range Information:

Range Minimum
$ 53,462.00

Range Midpoint
$ 77,860

Range Maximum
$ 102,258.00

Pay Transparency Statement:

Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.

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 .

Some states have required notifications. 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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