[Hiring] RN Case Management Coordinator @BlueCross BlueShield of South Carolina

Role Description

We are currently hiring for an RN Case Management Coordinator to join BlueCross BlueShield of South Carolina. In this role, care management interventions focus on improving care coordination and reducing the fragmentation of services recipients of care often experience, especially when multiple health care providers and different care settings are involved. These interventions enhance client safety, well-being, and quality of life while considering health care costs through the professional care manager's recommendations of cost-effective and efficient alternatives for care.

The professional care manager performs the primary functions of:

• Assessment
• Planning
• Facilitation
• Coordination
• Monitoring
• Evaluation
• Advocacy

Integral to these functions is collaboration and ongoing communication with the client, client's family or caregiver, and other health care professionals involved in the client's care.

This position is full-time (40 hours/week) Monday-Friday from 8:30am-5:00pm EST and will be fully remote.

What You’ll Do:

• Provides active care management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, including member goals.
• 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.
• Provides telephonic support for members with chronic conditions, high-risk pregnancy, or other at-risk conditions, including intensive assessment/evaluation of condition, at-risk education based on members’ identified needs, and member-centered coaching utilizing motivational interviewing techniques.
• 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.
• Serves as member advocate through continued communication and education.
• Promotes enrollment in care management programs and/or health and disease management programs.
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
• Performs medical or behavioral review/authorization process, ensuring 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 the system for clinical information flow and proper claims adjudication.
• Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies.
• 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

• Associates in a job-related field.
• Graduate of Accredited School of Nursing OR 2 years job-related work experience.

Requirements

• 4 years recent clinical experience in defined specialty area (oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedics, general medicine/surgery).
• 4 years utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical.
• 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.
• An active, unrestricted RN license 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).
• For Div. 75 and Div. 6B, URAC recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager.

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.