Remote RN: Utilization Management Coordinator II

001 BlueCross and BlueShield of South Carolina; South Carolina; Hybrid; USD 70,000 - 95,000; Full time

Benefits offered by this job

Education Assistance

Life Insurance

Paid Time Off (PTO)

On-site cafeterias and fitness centers

Job summary

BlueCross BlueShield of South Carolina is seeking a Managed Care Coordinator II – Utilization Management on a fully remote basis. You will review medical and behavioral eligibility, applying clinical criteria to service requests and health management interventions.

You will collaborate with Medical Directors, Case Managers, and other teams to ensure medical necessity, timely determinations, and proper documentation while supporting members in managing health and chronic conditions.

Qualifications

• Associate's degree in a related field is required.
• 4 years of recent clinical experience in a defined specialty or 4 years in utilization review/case management with 2 of 4 years clinical.
• Working knowledge of word processing software and quality improvement processes.
• Ability to work independently, prioritize, and make sound decisions with strong communication.
• Proficiency in spelling, punctuation, and grammar; strong presentation skills.

Responsibilities

• Performs medical or behavioral review/authorization process.
• Ensures coverage for services within guidelines of medical necessity.
• Documents clinical information to support medical necessity criteria.
• Collaborates with Care Management and other areas to ensure timely care processes.
• Provides discharge planning and evaluates service needs with providers.

Skills

Word processing software

Quality improvement processes

Contract language knowledge

Independent working

Customer service

Analytical thinking

Education

Associate's degree in a related field

Bachelor's degree (Nursing) preferred

Tools

Microsoft Office

Job description

BlueCross BlueShield of South Carolina is seeking a Managed Care Coordinator II – Utilization Management on a fully remote basis. You will review medical and behavioral eligibility, applying clinical criteria to service requests and health management interventions.

You will collaborate with Medical Directors, Case Managers, and other teams to ensure medical necessity, timely determinations, and proper documentation while supporting members in managing health and chronic conditions.