Coordinator, Managed Care II/UM-1

Why should you join the BlueCross BlueShield of South Carolina family of companies? We are the largest insurance company in South Carolina and much more. We are one of the nation's leading administrators of government contracts, operate one of the most sophisticated data processing centers in the Southeast, and have a diverse family of subsidiary companies. We deliver outstanding service to our customers and are deeply embedded in the South Carolina community.

About the role

Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions. Utilizes clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of the healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost-effective outcomes.

Responsibilities

• Performs medical or behavioral review/authorization process.
• Ensures coverage for appropriate services within benefit and medical necessity guidelines.
• 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 regulatory bodies (ERISA, NCQA, URAC, DOI, DOL).
• Provides discharge planning and assesses service needs in cooperation with providers and facilities.
• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• Collaborates with BCBSSC Care Management and other areas to ensure proper care management processes are executed within a timely manner.
• Manages assigned members and authorizations through appropriate communication.
• Provides appropriate communications (written, telephone) regarding requested services to both healthcare providers and members.
• Participates in direct intervention/patient education with members and providers regarding healthcare delivery system, utilization of networks, and benefit plans.
• May identify, initiate, and participate in on-site reviews.
• Promotes enrollment in care management programs and/or health and disease management programs.
• 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.

Requirements

• Required Education: Associate's in a job-related field.
• Required Experience: 4 years recent clinical experience in a defined specialty area (oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery) or 4 years utilization review/case management/clinical experience (2 of 4 years must be clinical).
• Required Skills and Abilities:
  • Working knowledge of word processing software.
  • Knowledge of quality improvement processes.
  • Knowledge of contract language and application.
  • Ability to work independently, prioritize effectively, and make sound decisions.
  • Good judgment and customer service skills.
  • Strong organizational and presentation skills.
  • Proficiency in spelling, punctuation, and grammar.
  • Strong 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.
• Required Software and Tools: Microsoft Office.
• Required License/Certificate: Active, unrestricted RN licensure in the state of hire or a compact multistate RN license as defined by the Nurse Licensure Compact (NLC), or active, unrestricted LMSW, Counselor, or Psychologist licensure in the state of hire.

Qualifications

• Preferred Education: Bachelor's degree in Nursing.
• Preferred Work Experience:
  • Background in Utilization Management.
  • Prior Project Management experience.
  • Experience supporting large, complex employer groups.
  • Experience handling PHI compliance with HIPAA.
• Preferred Skills and Abilities:
  • Working knowledge of spreadsheet and database software.
  • Thorough knowledge/understanding of claims/coding analysis, requirements, and processes.
  • Ability to communicate with providers and research/handle Prior Authorization escalations.
• Preferred Software and Tools: Microsoft Excel, Access, or other spreadsheet/database software.
• Preferred Licenses and Certificates: Case Manager Certification, clinical certification in specialty area.

Schedule

This is a remote position. The typical work hours are Monday - Friday from 8:30 AM - 5:00 PM.

Benefits

• 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.