Managed Care Coordinator II/CM-DM

BlueCross BlueShield of South Carolina
life insurance, paid holidays, tuition assistance, 401(k)
United States, South Carolina, Charleston
Nov 21, 2024
Summary We are currently hiring for a Managed Care Coordinator II/CM-DM to join BlueCross BlueShield of South Carolina. In this role Managed Care Coordinator II/CM-DM, you will review and evaluate medical and/or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests, or provide health management program interventions. You will also utilize clinical proficiency and claims knowledge/analysis; comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity options and services required to support members in managing their health, chronic illness, or acute illness. With this role, you will utilize available resources to promote quality, cost effective outcomes. Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we've been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina ... and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future. Description Logistics This position is full time (40 hours/week) Monday-Friday and will be fully remote (W@H). What You Will Do: Performs medical or behavioral review/authorization process. Ensures 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 system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). Provides discharge planning and assesses service needs in cooperation with providers and facilities. 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. Collaborates with BCBSSC Care Management and other areas to ensure proper care management processes are executed within a timely manner. Manages assigned members and authorizations through appropriate communication. Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members. 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. Promotes enrollment in care management programs and/or health and disease management programs. 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. To Qualify for This Position, You Will Need: Associates in a job-related field. Four years recent clinical in defined specialty area. Specialty areas include oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery, OR four years utilization review/case management/clinical/or combination; two of four 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. 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 (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. What We Prefer: Bachelor's degree - Nursing. Seven years of healthcare program management. Working knowledge of spreadsheet, database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. Working knowledge of Microsoft Excel, Access, OR other spreadsheet/database software. Case Manager Certification, clinical certification in specialty area. What We Can Do for You 401(k) retirement savings plan with company match. Subsidized health plans and free vision coverage. Life insurance. Paid annual leave - the longer you work here, the more you earn. Nine paid holidays. On-site cafeterias and fitness centers in major locations. Wellness programs and healthy lifestyle premium discount. Tuition assistance. Service recognition. Incentive Plan. Merit Plan. Continuing education funds for additional certifications and certification renewal. What to Expect Next After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Some states have required notifications. Here's more information. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities. If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.