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RN Managed Care Coordinator II – UM
BlueCross BlueShield of South Carolina. Review and evaluate medical or behavioral eligibility, benefits, and clinical criteria for service requests .
About the role
Key responsibilities & impact- Review and evaluate medical or behavioral eligibility, benefits, and clinical criteria for service requests
- Apply clinical expertise, administrative policies, and established clinical criteria to utilization management decisions
- Assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and required services
- Promote quality and cost-effective outcomes using available resources
- Perform medical or behavioral review and authorization processes
- Ensure coverage for appropriate services within benefit and medical necessity guidelines
- Make referrals to Medical Directors, Case Managers, Preventive Services, Subrogation, Quality of Care Referrals, and other appropriate staff
- Collect and input data for clinical information flow and claims adjudication
- Maintain compliance with applicable legislation and regulatory guidelines
- Provide discharge planning and assess service needs with providers and facilities
- Evaluate care-plan outcomes, eligibility, benefits, place of service, length of stay, medical necessity, and benefit exceptions
- Document clinical information supporting medical necessity criteria and contract benefits
- Collaborate with Care Management and other areas to execute care management processes timely
- Manage assigned members and authorizations through appropriate communication
- Communicate with healthcare providers and members by phone and in writing
- Participate in direct intervention and patient education regarding healthcare delivery systems, networks, and benefit plans
- Identify, initiate, and participate in on-site reviews when appropriate
- Promote enrollment in care management and health/disease management programs
- 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- Associate's in a job related field
- 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; OR 4 years utilization review/case management/clinical experience or combination, with 2 of 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 licensure from the United States and in the state of hire; OR active compact multistate unrestricted RN license under the Nurse Licensure Compact; OR 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: thorough knowledge of claims/coding analysis, requirements, and processes
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