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RN Managed Care Coordinator I
BlueCross BlueShield of South Carolina. Review and evaluate medical or behavioral eligibility for benefits and clinical criteria .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates clinical expertise in evaluating medical necessity and benefit eligibility while maintaining compliance with regulations such as ERISA and NCQA. Proficient in patient education, care management, and effective communication with healthcare providers and members.
Highest-signal resume keywords
Active RN LicensureClinical ExperienceUtilization ReviewPatient EducationMicrosoft Office Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Necessity EvaluationBenefit Eligibility AssessmentCare-Plan Compliance MonitoringClaims AdjudicationClinical Data CollectionDischarge PlanningCoding AnalysisContract Language KnowledgeHealthcare Program ManagementAnalytical Thinking
Soft Skills
Customer ServiceOrganizational SkillsPresentation SkillsDecision-MakingCommunication Skills
Tools & Technologies
Word Processing SoftwareSpreadsheet SoftwareDatabase Software
Certifications & Qualifications
Active RN LicensureActive LMSW LicensureCounselor LicensurePsychologist Licensure
Industry Keywords
ERISANCQAURACDOLHealthcare Delivery SystemsChronic Illness ManagementAcute Illness ManagementQuality of CareBenefit PlansConfidential Information Handling
About the role
Key responsibilities & impact- Review and evaluate medical or behavioral eligibility for benefits and clinical criteria
- Apply clinical expertise, administrative policies, and established clinical criteria to service requests
- Assess, plan, implement, coordinate, monitor, and evaluate medical necessity and care-plan compliance
- Support members managing chronic or acute illness and promote quality, cost-effective outcomes
- Perform medical or behavioral review and authorization processes
- Evaluate benefit eligibility, level of benefits, 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 supporting medical necessity criteria and contract benefits
- Identify and refer cases to Medical Directors, Case Managers, Preventive Services, Subrogation, and Quality of Care Referrals
- Participate in clinical data collection and system input for claims adjudication
- Maintain compliance with ERISA, NCQA, URAC, DOI, DOL, and other applicable regulations
- Provide patient education to members and providers about healthcare delivery systems, networks, and benefit plans
- Advocate for members through ongoing communication and education
- Promote enrollment in care management and health and disease management programs
- Maintain knowledge of provider contracts and network status
- Assist with claims information, discussion, and resolution
- Communicate with healthcare providers and members by telephone and in writing
Requirements
What you’ll need- Required Education: 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 proficiency
- Active, unrestricted RN licensure from the United States and in the state of hire, or active compact multistate unrestricted RN license under the Nurse Licensure Compact (NLC)
- Alternatively, active, unrestricted LMSW licensure from the United States and in the state of hire, or active, unrestricted Counselor or Psychologist licensure from the United States and in the state of hire
- Preferred: Bachelor's degree in Nursing
- Preferred: Healthcare program management, utilization review, or defined-specialty clinical experience
- Preferred: Working knowledge of spreadsheet and database software
- Preferred: Knowledge of contract language and application
- Preferred: Thorough knowledge of claims/coding analysis, requirements, and processes
- This position is not eligible for sponsorship now or in the future
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 to company growth
- Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs