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Case Management Coordinator – Oncology 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, clinical assessment, and patient advocacy while ensuring compliance with regulatory guidelines. Proficient in developing member-centered action plans and conducting evaluations of medical necessity and benefit levels.
Highest-signal resume keywords
Active RN LicenseClinical Experience in OncologyUtilization Review ExperienceCase Management CertificationKnowledge of Regulatory Guidelines
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 AssessmentCare ManagementMedical Necessity EvaluationPatient EducationMotivational InterviewingQuality Improvement ProcessesClaims AnalysisContract Language KnowledgeData CollectionDocumentation Accuracy
Soft Skills
Good JudgmentOrganizational SkillsPresentation SkillsOral Communication SkillsWritten Communication Skills
Tools & Technologies
Microsoft OfficeWord Processing SoftwareSpreadsheet SoftwareDatabase Software
Certifications & Qualifications
Active RN LicenseURAC-recognized Case Management CertificationClinical Certification in Specialty Area
Industry Keywords
Care ManagementHealth Care DeliveryBenefit PlansRegulatory CompliancePatient AdvocacyChronic ConditionsHigh-Risk PregnancyOncologyMental HealthUtilization Review
About the role
Key responsibilities & impact- Provide active care management and assess members' service needs
- Develop and coordinate member-centered action plans and monitor services
- Evaluate plan outcomes, eligibility, benefit levels, place of service, length of stay, medical necessity, and benefit exceptions
- Document clinical information accurately to support medical necessity determinations and contract benefits
- Provide telephonic support for members with chronic conditions, high-risk pregnancy, or other at-risk conditions
- Conduct intensive assessments, at-risk education, coaching, motivational interviewing, reflective listening, and readiness-to-change assessments
- Participate in direct intervention and patient education with members and providers regarding health care delivery, networks, and benefit plans
- Identify, initiate, and participate in on-site reviews when needed
- Serve as a member advocate through ongoing communication and education
- Promote enrollment in care management and health/disease management programs
- Communicate with health care providers and members regarding requested services
- Perform medical or behavioral review and authorization processes
- Ensure appropriate service coverage within benefit and medical necessity guidelines
- Make referrals 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 clinical information flow and claims adjudication
- Maintain compliance with applicable legislation and regulatory guidelines, including ERISA, NCQA, URAC, DOI, and DOL
- Maintain current knowledge of contracts and provider network status
- Assist with claims information, discussion, and resolution, referring issues to internal support areas
Requirements
What you’ll need- Associate's in a job related field
- Graduate of Accredited School of Nursing or 2 years job related work experience
- 4 years recent clinical experience in a defined specialty area, including oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, or general medicine/surgery
- Alternatively, 4 years utilization review/case management/clinical experience or combination, with 2 of the 4 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 Nurse Licensure Compact, or active unrestricted social worker, counselor, or psychologist licensure as applicable
- 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: Bachelor's degree in Nursing
- Preferred: 3+ years of Oncology experience
- Preferred: spreadsheet and database software knowledge
- Preferred: claims/coding analysis, requirements, and processes knowledge
- 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