RN Managed Care Coordinator I - Part Time

BlueCross BlueShield of South Carolina; South Carolina; Remote; USD 50,000 - 80,000; Part time

Job summary

An established industry player is seeking a dedicated RN Managed Care Coordinator I to join their team. This part-time role offers the flexibility of remote work while ensuring quality care for members. You will leverage your clinical expertise to evaluate medical eligibility, coordinate care plans, and advocate for patients. With a commitment to promoting health and wellness, this position provides an opportunity to make a meaningful impact in the lives of others. Join a supportive environment that values your contributions and offers comprehensive benefits, including health plans and a 401k match.

Benefits

Subsidized health, dental, and vision plans

401k with company match

Life Insurance

Paid Time Off (PTO)

Qualifications

• Active RN licensure in the U.S. and relevant state.
• Minimum 2 years of clinical experience required.

Responsibilities

• Conduct medical reviews to ensure compliance with guidelines.
• Educate members on healthcare delivery and benefits.

Skills

Clinical Experience

Communication Skills

Analytical Skills

Customer Service

Organizational Skills

Decision Making

Confidentiality Handling

Negotiation Skills

Education

Associates Degree in Nursing

Bachelor's Degree in Nursing

Tools

Microsoft Office

Job description

RN Managed Care Coordinator I - Part Time

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Summary
We are currently hiring for an RN Managed Care Coordinator I to join BlueCross BlueShield of South Carolina. In this role, 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. You will utilize 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. You will utilize available resources to promote quality, cost-effective outcomes.

Description
Location: This position is part-time (30 hours/week), Monday-Friday, from 8:30am-5:00pm EST, and will be fully remote. Candidates may be asked to report on-site for 3 days for training and to obtain equipment.

What You’ll Do

• Perform medical or behavioral review/authorization processes, ensuring coverage within benefit and medical necessity guidelines. Evaluate outcomes, eligibility, benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. Initiate or coordinate discharge planning or alternative treatment plans as necessary. Ensure accurate documentation of clinical information to support medical necessity criteria and contract benefits.
• Utilize allocated resources to support review determinations. Make referrals to appropriate staff (Medical Director, Case Manager, etc.). Participate in data collection and input for clinical information flow and claims adjudication. Comply with all applicable legislation and guidelines (e.g., ERISA, NCQA, URAC, state and federal regulations).
• Provide patient education to members and providers regarding healthcare delivery, network utilization, and benefit plans. Serve as a member advocate through ongoing communication and education. Promote enrollment in care management and disease management programs.
• Maintain current knowledge of contracts and network status of all service providers. Assist with claims discussions and resolution, referring to support areas as needed.
• Communicate effectively (written and verbal) with healthcare providers and members regarding requested services.

Qualifications

• Associates degree in a related field or graduate of an accredited Nursing school with 2 years of relevant experience.
• Minimum 2 years of clinical experience.
• Working knowledge of word processing software, Microsoft Office.
• Ability to work independently, prioritize tasks, and make sound decisions.
• Strong judgment, customer service, organizational, and communication skills.
• Proficiency in typing, spelling, punctuation, grammar, and oral communication.
• Ability to persuade, negotiate, and influence others.
• Analytical and critical thinking skills.
• Ability to handle confidential information discreetly.
• Active RN licensure in the U.S. and in the state of hire, or a multistate compact RN license, or relevant licensure (LMSW, Counselor, Psychologist).

Preferred Qualifications

• Bachelor's Degree in Nursing.
• One year of Utilization Review experience.
• Ability to work independently and influence others.

Benefits

• Subsidized health, dental, and vision plans.
• 401k with company match.
• Life Insurance, PTO, and other benefits.

Our Commitment

We value diversity and inclusivity, offering accommodations and equal employment opportunities in accordance with applicable laws.