RN Managed Care Coordinator I

🕒 September 8

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 43%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

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

• Review and evaluate medical or behavioral eligibility for benefits and clinical criteria using clinical expertise, administrative policies, and established criteria • Assess, plan, implement, coordinate, monitor, and evaluate medical necessity and care plan compliance, options, and services • Promote quality and cost-effective outcomes using available resources • Perform medical or behavioral review and authorization processes • Ensure coverage for appropriate services within benefit and medical necessity guidelines • Evaluate plan outcomes, eligibility, benefit levels, place of service, length of stay, and medical necessity • Initiate or coordinate discharge planning and alternative treatment plans when appropriate • Document clinical information accurately to support medical necessity determinations and contract benefits • Use allocated resources to support review determinations and refer cases to appropriate staff • Participate in clinical data collection and system input for information flow and claims adjudication • Comply with applicable legislation and regulatory guidelines, including ERISA, NCQA, URAC, state DOI, and federal DOL requirements • Provide patient education to members and providers regarding healthcare delivery, networks, and benefit plans • Advocate for members through ongoing communication and education • Promote enrollment in care management and health/disease management programs • Maintain current knowledge of provider contracts and network status • Assist with claims information, discussion, and resolution • Communicate with healthcare providers and members by telephone and in writing

🎯 Requirements

• Associate degree in a job-related field required • Graduate of an Accredited School of Nursing or 2 years of job-related work experience as degree equivalency • 2 years’ clinical experience • 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 • Microsoft Office proficiency • Active, unrestricted RN licensure from the United States and in the state of hire, or active compact multistate unrestricted RN license under the Nurse Licensure Compact (NLC) • Alternatively, active unrestricted LMSW, Counselor, or Psychologist licensure from the United States and in the state of hire • Preferred: bachelor's degree in Nursing • Preferred experience in healthcare program management, utilization review, or clinical experience in a defined specialty • Preferred working knowledge of spreadsheet and database software • Preferred knowledge of contract language and application • Preferred knowledge of claims/coding analysis, requirements, and processes • Ability to work Monday-Friday, 8:00am-5:00pm EST

🏖️ 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

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume