Coordinator, Managed Care II – UM-1

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🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

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BlueCross BlueShield of South Carolina

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1946

🏥 Healthcare

💼 Consulting

⚖️ Legal

Healthcare • Consulting • Legal

BlueCross BlueShield of South Carolina is a leading health insurance provider that offers a variety of health plans, including individual and family plans, Medicare options, and group health plans. The organization focuses on providing coverage and resources for members, employers, and healthcare providers, ensuring access to quality healthcare services. With a commitment to promoting healthier lifestyles and supporting community health, BlueCross BlueShield of South Carolina plays a vital role in the healthcare landscape of the region.

📋 Description

• Perform medical or behavioral review and authorization processes • Ensure coverage for appropriate services within benefit and medical necessity guidelines • Use allocated resources to support review determinations • Identify and make referrals to Medical Directors, Case Managers, Preventive Services, Subrogation, and quality-of-care teams • Participate in clinical data collection and system input for claims adjudication • Comply with applicable legislation and regulatory guidelines, including ERISA, NCQA, URAC, DOI, and DOL requirements • Provide discharge planning and assess service needs with providers and facilities • Evaluate plans, eligibility, benefits, place of service, length of stay, medical necessity, and benefit exceptions • Document clinical information supporting medical necessity and contract benefits • Collaborate with Care Management and other areas to execute care management processes timely • Manage assigned members and authorizations through appropriate communication • Communicate requested-service information to healthcare providers and members in writing and by telephone • Participate in patient education and direct intervention regarding healthcare delivery, network utilization, and benefit plans • Identify, initiate, and participate in on-site reviews • Promote enrollment in care management and health/disease management programs • Maintain current knowledge of contracts and provider network status • Assist with claims information, discussion, and resolution; refer issues to internal support areas

🎯 Requirements

• Associate's degree in a job-related field • 4 years of recent clinical experience in a defined specialty area, including oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedics, or general medicine/surgery; OR 4 years of utilization review, case management, clinical experience, or combination, with 2 of 4 years 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 spelling, punctuation, and grammar proficiency • 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 discreetly • Microsoft Office proficiency • Active, unrestricted United States RN license and state-of-hire licensure, or active compact multistate unrestricted RN license under the NLC, or active unrestricted United States LMSW license and state-of-hire licensure, or active unrestricted counselor or psychologist licensure and state-of-hire licensure • Preferred: bachelor's degree in nursing • Preferred: utilization management background, project management experience, experience supporting large complex employer groups, and HIPAA PHI compliance experience • Preferred: working knowledge of spreadsheet/database software and claims/coding analysis • Preferred: Case Manager Certification or clinical certification in a specialty area

🏖️ Benefits

• Subsidized health plans, dental and vision coverage • 401 k 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