[Hiring] Managed Care Coordinator I @BlueCross BlueShield of South Carolina

Role Description

We are currently hiring for a 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.
• Utilize available resources to promote quality, cost-effective outcomes.

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:

• Perform medical or behavioral review/authorization process.
• Ensure coverage for appropriate services within benefit and medical necessity guidelines.
• Evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• Initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate.
• Ensure accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• Utilize allocated resources to back up review determinations.
• Identify and make referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.).
• Participate in data collection/input into system for clinical information flow and proper claims adjudication.
• Demonstrate compliance with all applicable legislation and guidelines for all regulatory bodies.
• Provide patient education with members and providers regarding health care delivery system, utilization on networks, and benefit plans.
• Serve as member advocate through continued communication and education.
• Promote enrollment in care management programs and/or health and disease management programs.
• Maintain current knowledge of contracts and network status of all service providers and apply appropriately.
• Assist with claims information, discussion, and/or resolution and refer to appropriate internal support areas.
• Provide appropriate communications (written, telephone) regarding requested services to both health care providers and members.

Qualifications

• 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), 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.

Requirements

• Preferred Education: Bachelor's degree in Nursing.
• Preferred Work Experience: Work experience in healthcare program management, utilization review, or clinical experience in defined specialty areas such as 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

• 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.