Remote RN: Utilization Management Coordinator II

Southcarolinablues; Northern (KY); Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Health plans

401k retirement plan

Paid Time Off (PTO)

Education Assistance

Life Insurance

Job summary

BlueCross BlueShield of South Carolina is hiring a Managed Care Coordinator II – Utilization Management for a fully remote role with occasional on-site trainings. You will review medical and behavioral requests, applying clinical criteria and contracts to determine medical necessity and benefits coverage.

You will also support discharge planning, coordinate with care teams, and educate members and providers on care options while ensuring regulatory compliance and accurate documentation.

Qualifications

• Associate's degree in a related field required.
• 4 years' clinical experience or utilization review/case management with clinical background.
• Active RN license in the United States (or multi-state via compact).
• Knowledge of clinical criteria, quality programs, and contracts.

Responsibilities

• Perform medical/behavioral review and authorization per rules.
• Document determinations and coordinate with care management teams.
• Provide discharge planning and assess service needs with providers.
• Communicate with providers and members about services and benefits.
• Maintain knowledge of contracts and network status; support claims processes.

Skills

RN licensure (US)

Utilization management

Clinical review

Communication

Microsoft Office

Education

Associate's degree in related field

Bachelor's degree in Nursing

Tools

Microsoft Office

Job description

BlueCross BlueShield of South Carolina is hiring a Managed Care Coordinator II – Utilization Management for a fully remote role with occasional on-site trainings. You will review medical and behavioral requests, applying clinical criteria and contracts to determine medical necessity and benefits coverage.

You will also support discharge planning, coordinate with care teams, and educate members and providers on care options while ensuring regulatory compliance and accurate documentation.