Remote RN: Managed Care Coordinator I

Southcarolinablues; South Carolina; À distance; USD 60 000 - 90 000; Plein temps

Avantages offerts par ce poste

Subsidized health plans

401k retirement savings plan with team

Life Insurance

PTO (Paid Time Off)

Education Assistance

Résumé du poste

BlueCross BlueShield of South Carolina is seeking an RN Managed Care Coordinator I to review medical eligibility and apply clinical criteria for benefits. This full-time, fully remote role operates Monday–Friday, EST hours, with occasional onsite trainings as needed.

The position requires an RN license (US or compact), 2 years of clinical experience, and strong communication, documentation, and decision-making skills.

Qualifications

• Associates in a job-related field required.
• Graduate of Accredited School of Nursing or 2 years of job-related work experience.
• Active RN licensure or equivalent licensure as allowed (NLC/LMSW/Counselor/Psychologist) required.
• Strong communication, documentation, and data entry skills.

Responsabilités

• Performs medical/behavioral review/authorization within guidelines.
• Ensures coverage for services per benefits and medical necessity.
• Evaluates plans, eligibility, and medical necessity of requests.
• May coordinate discharge planning or alternative treatment plans.
• Documents clinical information to support medical necessity criteria.
• Coordinates with Medical Director, Case Manager, and quality referrals.
• Participates in data collection for claims adjudication.
• Ensures compliance with ERISA, NCQA, URAC, DOI, and other regulations.
• Provides patient education to members and providers.
• Advocates for members and promotes enrollment in care management programs.
• Maintains knowledge of contracts and provider network status.
• Assists with claims information and issue resolution.

Connaissances

Analytical thinking

Communication

Decision making

Customer service

Organizational skills

Oral and written communication

Formation

Graduate of Accredited School of Nursing

Associate degree in nursing or related field

Outils

Microsoft Office

Description du poste

BlueCross BlueShield of South Carolina is seeking an RN Managed Care Coordinator I to review medical eligibility and apply clinical criteria for benefits. This full-time, fully remote role operates Monday–Friday, EST hours, with occasional onsite trainings as needed.

The position requires an RN license (US or compact), 2 years of clinical experience, and strong communication, documentation, and decision-making skills.