RN Managed Care Coordinator I

🔥 9 minutes ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.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.

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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

• Review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria for service requests • 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 plans, eligibility, benefit levels, place of service, length of stay, medical necessity, and benefit exceptions • Initiate or coordinate discharge planning and alternative treatment plans when appropriate • Document clinical information to support medical necessity criteria and contract benefits • Identify and refer cases to Medical Directors, Case Managers, Preventive Services, Subrogation, Quality of Care Referrals, and other 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, DOI, and DOL requirements • Educate members and providers regarding healthcare delivery systems, network utilization, 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 contracts and provider network status • Assist with claims information, discussion, and resolution, referring issues to internal support areas • Communicate with healthcare providers and members by telephone and in writing regarding requested services

🎯 Requirements

• Associates in a job-related field • Graduate of Accredited School of Nursing or 2 years of job-related work experience • 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 • 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 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 • Preferred: Bachelor's degree in Nursing • Preferred: Work 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: Thorough knowledge/understanding of claims, coding analysis, requirements, and 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 • Diverse and inclusive workplace • Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs