RN Managed Care Coordinator II - UM

ourhrconnect; United States; Remote; USD 85,000 - 110,000; Full time

Job summary

BlueCross BlueShield of South Carolina is hiring a Managed Care Coordinator II - Utilization Management. The role reviews clinical criteria to determine medical necessity and coordinates care management for members.

The position is full time, remote, with potential on-site trainings. Requires 4 years clinical experience in defined areas or utilization review/case management, plus active US licensure in nursing or related fields.

Qualifications

• Requires Associate's in a related field.
• RN licensure active in US states or LMSW/licensure in relevant fields.
• 4 years clinical or utilization review experience in specified areas.

Responsibilities

• Perform medical/behavioral review and authorization per guidelines.
• Provide discharge planning and assess service needs with providers.
• Communicate with providers and members about requested services.
• Promote care management programs and ensure timely processes.
• Maintain knowledge of contracts and network status of providers.

Skills

Word processing

Quality improvement

Contract language

Independent work

Decision making

Customer service

Oral communication

Written communication

Analytical thinking

Confidential handling

Negotiation skills

Education

Associate's degree

Bachelor's degree (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.

Description

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.

To Qualify for This Position, You'll Need the Following:

• 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.

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 sp