Remote RN Managed Care Coordinator I

BlueCross and BlueShield of South Carolina; United States; À distance; USD 65 000 - 85 000; Plein temps

Résumé du poste

BlueCross and BlueShield of South Carolina seeks an RN Managed Care Coordinator I to review medical/behavioral eligibility against benefits and clinical criteria. You will apply clinical expertise and administrative policies to ensure medical necessity and care plan compliance for members managing their health.

Remote role with potential onsite trainings. Requires an active RN license in the United States or a nurse license in state of hire, plus 2 years of clinical experience and strong

Qualifications

• Requires Associates in a related field or nursing equivalence.
• RN licensure active in US state or compact license, or LMSW/ Counselor/Psychologist licensure as applicable.
• 2 years of clinical experience required.
• Working knowledge of word processing software.
• Ability to work independently, prioritize, and make sound decisions.
• Strong customer service, organizational, and presentation skills.
• Excellent written and oral communication; proficient typing and grammar.

Responsabilités

• Performs medical/behavioral review and authorization.
• Ensures coverage aligns with benefits and medical necessity guidelines.
• Evaluates outcomes of plans, eligibility, and level of benefits.
• Initiates discharge planning or alternative treatment plans when needed.
• Documents clinical information to support medical necessity criteria.
• Collaborates with Medical Director, Case Manager, and other staff as required.
• Participates in data entry for clinical information flow and claims.
• Complies with ERISA, NCQA, URAC, DOI, and DOL guidelines.
• Educates members and providers about care delivery networks and benefits.
• Advocates for members and promotes enrollment in care management programs.

Connaissances

Independent work

Prioritization

Decision making

Customer service

Communication

Typing accuracy

Analytical thinking

Confidentiality

Office software

Formation

Associate degree in related field

Nursing degree equivalency

Outils

Microsoft Office

Description du poste

BlueCross and BlueShield of South Carolina seeks an RN Managed Care Coordinator I to review medical/behavioral eligibility against benefits and clinical criteria. You will apply clinical expertise and administrative policies to ensure medical necessity and care plan compliance for members managing their health.

Remote role with potential onsite trainings. Requires an active RN license in the United States or a nurse license in state of hire, plus 2 years of clinical experience and strong