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Case Management Coordinator, Maternity Focus
BlueCross BlueShield of South Carolina. Provide active care management and assess members’ service needs .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in care management, including assessment of service needs, eligibility, and medical necessity, while effectively communicating with members and providers. Proficient in utilizing motivational interviewing and reflective listening techniques to educate and advocate for members in various health care settings.
Highest-signal resume keywords
Active RN LicenseCare ManagementUtilization ReviewMotivational InterviewingClaims Adjudication
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical AssessmentBenefit AnalysisQuality Improvement ProcessesContract Language KnowledgeClaims/Coding Analysis
Soft Skills
Customer ServiceOrganizational SkillsPresentation SkillsAnalytical ThinkingDecision Making
Tools & Technologies
Microsoft OfficeWord Processing SoftwareSpreadsheet SoftwareDatabase Software
Certifications & Qualifications
URAC-Recognized Case Management CertificationCase Manager Certification
Industry Keywords
ERISANCQAURACDOLMedical Necessity Guidelines
About the role
Key responsibilities & impact- Provide active care management and assess members’ service needs
- Develop, coordinate, monitor, and evaluate member-centered action plans
- Assess eligibility, benefit levels, place of service, length of stay, medical necessity, and benefit exceptions
- Document clinical information supporting medical necessity and contract benefits
- Provide telephonic support for members with chronic conditions, high-risk pregnancy, and other at-risk conditions
- Deliver condition-specific education and member-centered coaching using motivational interviewing, reflective listening, and readiness-to-change assessment
- Educate and intervene directly with members and providers regarding health care delivery, networks, and benefit plans
- Identify, initiate, and participate in on-site reviews
- Advocate for members through continued communication and education
- Promote enrollment in care management and health and disease management programs
- Communicate requested-service information to health care providers and members in writing and by telephone
- Perform medical or behavioral review and authorization processes
- Ensure service coverage complies with benefit and medical necessity guidelines
- Make referrals to Medical Directors, Case Managers, Preventive Services, Subrogation, and Quality of Care teams
- Collect and input clinical information for proper claims adjudication
- Comply with ERISA, NCQA, URAC, DOI, DOL, and other applicable regulations
- Maintain current knowledge of contracts and provider network status
- Assist with claims information, discussion, and resolution; refer issues to internal support areas
Requirements
What you’ll need- Associates in a job related field
- 2 years job related work experience may satisfy degree equivalency
- 4 years recent clinical experience in a defined specialty area, including maternity, or 4 years utilization review/case management/clinical experience, with 2 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 proficiency in spelling, punctuation, and grammar
- 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 license from the United States and the state of hire, or active compact multistate unrestricted RN license under the NLC, or active unrestricted social worker license, counselor license, or psychologist license as specified
- For Div. 75 and Div. 6B, except for CC 426: URAC-recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager
- Preferred: 4+ years of maternity experience
- Preferred: working knowledge of spreadsheet and database software
- Preferred: knowledge of claims/coding analysis, requirements, and processes
- Preferred: Case Manager certification and clinical certification in specialty area
Benefits
Comp & perks- 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
- Opportunity to develop skills, advance careers, and contribute unique abilities