Logo of Huzzle

Home

Matches

Explore

Manage

RN Managed Care Coordinator I

image

BlueCross BlueShield of South Carolina

Aug 29, 2024

  • Job
    Full-time
    Junior Level
  • United Kingdom, +4
    Remote
  • Quick Apply

AI generated summary

  • You need an associate's degree in a related field, RN licensure, two years of clinical experience, strong communication skills, and proficiency in Microsoft Office.
  • You will review and authorize services, coordinate care plans, evaluate outcomes, educate members, and ensure compliance while advocating for patients' needs and managing chronic conditions.

Requirements

  • To Qualify For This Position, You Will Need
  • Associates in a job-related field
  • Graduate of Accredited School of Nursing
  • Two-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 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
  • Work experience in healthcare program management, utilization review, OR clinical experience in defined specialty
  • Specialty areas are oncology, cardiology, neonatology, maternity, rehabilitation services, orthopedic, general medicine/surgery
  • Working knowledge of spreadsheet, database software
  • Knowledge of contract language and application
  • Thorough knowledge/understanding of claims/coding analysis/requirements/processes

Responsibilities

  • Performs medical OR behavioral review/authorization process.
  • Ensures coverage for appropriate services within benefit and medical necessity guidelines.
  • Assesses service needs, develops, and coordinates action plans in cooperation with members, monitors services, and implements plans.
  • Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
  • May initiate/coordinate discharge planning OR alternative treatment plan as necessary and appropriate.
  • Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
  • 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).
  • Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.
  • Serves as member advocate through continued communication and education.
  • Promotes enrollment in care management programs and/or health and disease management programs.
  • Provides telephonic support for members with chronic conditions, high risk pregnancy OR other at-risk conditions that consist of intensive assessment/evaluation of condition, at risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement.
  • 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.
  • Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

FAQs

Do we support remote work?

Yes, this position is fully remote (work from home).

What qualifications are required for this position?

You need to have an Associate's degree in a job-related field, graduate from an accredited school of nursing, and possess active, unrestricted RN licensure or other relevant licensure in the state of hire.

How much clinical experience is needed for this role?

A minimum of two years of clinical experience is required.

Is a Bachelor's degree preferred for this position?

Yes, a Bachelor's degree in Nursing is preferred for this role.

What are the primary responsibilities of the RN Managed Care Coordinator I?

The primary responsibilities include reviewing medical eligibility, assessing medical necessity, developing action plans, coordinating care, monitoring services, and providing patient education.

What software skills are necessary for this position?

A working knowledge of word processing software and proficiency in Microsoft Office are necessary. Experience with spreadsheet and database software is preferred.

What kind of benefits does BlueCross BlueShield of South Carolina offer?

Benefits include a 401(k) retirement savings plan with company match, subsidized health plans, paid annual leave, tuition assistance, wellness programs, and more.

Are there opportunities for continuing education?

Yes, the company offers continuing education funds for additional certifications and certification renewal.

What are the working hours for this position?

This is a full-time position working 40 hours a week, Monday through Friday.

Is experience in healthcare program management or utilization review a requirement?

While not required, work experience in healthcare program management, utilization review, or clinical experience in a defined specialty is preferred.

What does the recruitment process look like?

After submitting your application, the recruiting team will review your resume. This may include a brief phone interview or email communication with a recruiter, followed by interviews for qualified candidates.

How does the company promote equal employment opportunities?

BlueCross BlueShield of South Carolina follows a policy of nondiscrimination in employment and maintains Affirmative Action programs to promote opportunities for minorities, females, disabled individuals, and veterans.

Can I request accommodations during the hiring process if needed?

Yes, the company is committed to providing reasonable accommodations for individuals with physical and mental disabilities. You can reach out for assistance via email or phone.

image

BlueCross BlueShield of South Carolina

South Carolina’s largest and oldest health insurance company

Finance
Industry
10,001+
Employees
1946
Founded Year

Mission & Purpose

BlueCross BlueShield of South Carolina, the state's largest insurance company, has been a part of the national landscape for over six decades. With an A+ Superior rating from A.M. Best, the company is a leading government contract administrator and operates one of the most advanced data processing centers in the Southeast. BlueCross offers employees robust benefits, including retirement plans, health coverage, and education assistance, while fostering a culture of community support, with employees actively contributing to numerous nonprofit organizations each year.