RN Managed Care Coordinator II - UM

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

Summary

We are currently hiring for a Managed Care Coordinator II – Utilization Management to join BlueCross BlueShield of South Carolina. In this role as a Managed Care Coordinator II – Utilization Management, 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 or provides health management program interventions. Utilizes clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, 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-Sunday from 8:00am – 4:30pm EST and will be fully remote. The candidate may be asked to report on-site occasionally for trainings, meetings, or other business needs.

What You’ll Do

• Performs medical or behavioral review/authorization process.
• Ensures coverage for appropriate services within benefit and medical necessity guidelines.
• 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 discharge planning and assesses service needs in cooperation with providers and facilities.
• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• Collaborates with BCBSSC Care Management and other areas to ensure proper care management processes are executed within a timely manner.
• Manages assigned members and authorizations through appropriate communication.
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
• Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.
• May identify, initiate, and participate in on-site reviews.
• 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.

Qualifications

• Required Education: Associate's in a job related field.
• Required Experience: 4 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery.
• OR, 4 years utilization review/case management/clinical/or combination; 2 of 4 years must be clinical.
• Required Skills and Abilities: Working knowledge of word processing software. Knowledge of quality improvement processes and demonstrated ability with these activities. Knowledge of contract language and application. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in 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 Other Tools: Microsoft Office.
• Required License/Certificate: 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), OR, active, unrestricted LMSW (Licensed Master of Social Work) licensure from the United States and in the state of hire, OR active, unrestricted licensure as Counselor, or Psychologist from the United States and in the state of hire.

Preferred

• 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.

Benefits

• 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 will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Veterans Welcome!

BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty.