RN Managed Care Coordinator I

Southcarolinablues; Northern (KY, SC); Hybrid; USD 60,000 - 85,000; Full time

Benefits offered by this job

Subsidized health plans

401k retirement savings plan with公司

Life Insurance

Paid Time Off (PTO)

Education Assistance

Service Recognition

National discounts

Job summary

BlueCross BlueShield of South Carolina is seeking a Managed Care Coordinator I to review medical or behavioral eligibility and apply clinical criteria to service requests. You will assess medical necessity, coordinate care, and promote quality, cost-effective outcomes for members.

This full-time remote role requires RN/LMSW/Licensed Counselor/ Psychologist credentials, 2 years of clinical experience, and strong communication.

Qualifications

• Associates in a job-related field required.
• RN licensure (state of hire) or compact multistate license.
• LMSW licensure in the United States and in the state of hire; Counselor or Psychologist licensure also required.

Responsibilities

• Perform medical/behavioral review and authorization processes.
• Ensure coverage aligns with guidelines and medical necessity.
• Document clinical information to support determinations and contract benefits.
• Coordinate discharge planning or alternate treatment plans as needed.
• Communicate with providers and members regarding services.

Skills

Word processing

Independent work

Decision making

Customer service

Communication skills

Analytical thinking

Confidentiality handling

Education

Associates in a job-related field

Nurse education equivalency

Graduate of Accredited School of Nursing

Tools

Microsoft Office

Job description

Summary

We are currently hiring for a Managed Care Coordinator I to join BlueCross BlueShield of South Carolina. In this role as a Managed Care Coordinator I, you will review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests. Utilizes clinical proficiency and claims knowledge/analysis to assess, plan, implement, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective outcomes.

Location

This position is full time (40 hours/week) Monday-Friday from 8:00am – 5:00pm EST and will be fully remote in South Carolina.

What You’ll Do

• Performs medical or behavioral review/authorization process.
• Ensures coverage for appropriate services within benefit and medical necessity guidelines.
• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate.
• Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• 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).
• Provides patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.
• Serves as member advocate through continued communication and education.
• Promotes enrollment in care management programs and/or health and disease management programs.
• 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.
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

To Qualify for This Position

Required Education

Associates in a job-related field.

Degree Equivalency

Graduate of Accredited School of Nursing or 2 years of job-related work experience.

Required Work Experience

2 years’ clinical experience.

Required Skills and Abilities

• Working knowledge of word processing software.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills.
• Demonstrated customer service, organizational, and presentation skills.
• Demonstrated proficiency in typing, 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

• Active, unrestricted RN licensure 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),
• Active, unrestricted LMSW (Licensed Master of Social Work) licensure from the United States and in the state of hire,
• Active, unrestricted licensure as Counselor, or Psychologist from the United States and in the state of hire.

We Prefer That You Have the Following

Preferred Education

Bachelor's degree- Nursing.

Preferred Work Experience

Work experience in healthcare program management, utilization review, or clinical experience in defined specialty. Specialty areas are oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery.

Preferred Skills and Abilities

• Working knowledge of spreadsheet, database software.
• Knowledge of contract language and application.
• Thorough knowledge/understanding of claims/coding analysis/requirements/processes.

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.

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 participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.