Remote Managed Care Coordinator; RN​/CM-DM

Why should you join the Blue Cross Blue Shield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. Business and political climates may change, but we’re stronger than ever. Our A.M. Best rating is A+ (Superior) — making us the only health insurance company in South Carolina with that rating.

We’re the largest insurance company in South Carolina …and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers.

If you are dedicated to the same philosophy, consider joining our team!

Job Title:

Coordinator, Managed Care II/CM-DM

Position Details:

• CONTRACT TO HIRE
  - Not a long-term contract role.
• APPLICANTS MUST HAVE ANY OF THE FOLLOWING EXPERIENCE TO BE CONSIDERED FOR THE POSITION, CRITICAL CARE EXPERIENCE, ICU, ER, cardiac PACU, Progressive care unit or Step-down units
• Remote/Hybrid (depends on the pace of the employee and validation of competency)
• Training Onsite (Travel is covered/Reimbursed by BCBS) Should expect to be in office for orientation for at least 4 weeks.
• MUST LIVE IN SOUTH CAROLINA, must have a valid South Carolina RN license
• Hours/
  
  Schedule:
  
  8AM-430PM M-F and Call every 4-6 weeks once fully trained-Call will not begin for at least 3 months. Call hours are less than 6 hours per weekend assigned, there are exceptions to this and will be reviewed with Management
• Teams Interview with Program Manager

Duties:

• 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 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.
• 60% Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals. 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.
  
  Provides telephonic support for members with chronic conditions, high risk pregnancy or other at risk conditions that consist of: intensive assessment/evaluation of condition, at risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement.
• 20% 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…