Coordinator, Managed Care II/CM-DM

About the position We are currently hiring for a Managed Care Coordinator II in Behavioral Health to join BlueCross BlueShield of South Carolina. In this role as the Managed Care Coordinator II, you will review and evaluate medical and/or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests, or provide health management program interventions. You will also utilize clinical proficiency and claims knowledge/analysis to assess and evaluate medical necessity for services required to support members in managing their health, chronic illness, or acute illness. With this role, you will utilize available resources to promote quality, cost effective outcomes. This position is full time (40 hours/week) Monday-Friday and will be fully remote (W@H). You will provide active care management, assess service needs, develop, and coordinate action plans in cooperation with members, monitor services and implement plans, to include member goals. You will evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. Ensuring accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits is crucial. You will provide 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, and provide 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. Additionally, you will participate in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks, and benefit plans. As a member advocate, you will ensure continued communication and education, promote enrollment in care management programs and/or health and disease management programs, and provide appropriate communications regarding requested services to both health care providers and members. Responsibilities • Provides active care 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. , • Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. , • May identify, initiate, and participate in on-site reviews. , • Serves as member advocate through continued communication and education. , • Promotes enrollment in care management programs and/or health and disease management programs. , • Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members. , • 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 all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). , • 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 • Associates in a job-related field. , • Four years recent clinical in defined specialty area. , • An active, unrestricted RN license from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR active, unrestricted licensure as social worker from the United States and in the state of hire (in Div. 6B), OR active, unrestricted licensure as counselor, OR psychologist from the United States and in the state of hire (in Div. 75 only). , • 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 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. Nice-to-haves • Bachelor's degree - Nursing. , • Seven years of healthcare program management. , • Five years of Behavioral Health and Case Management experience. , • Crisis Management experience. , • Working knowledge of spreadsheet, database software. , • Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. , • Working knowledge of Microsoft Excel, Access, OR other spreadsheet/database software. , • Case Manager Certification, clinical certification in specialty area. Benefits • 401(k) retirement savings plan with company match. , • Subsidized health plans and free vision coverage. , • Life insurance. , • Paid annual leave - the longer you work here, the more you earn. , • Nine paid holidays. , • On-site cafeterias and fitness centers in major locations. , • Wellness programs and healthy lifestyle premium discount. , • Tuition assistance. , • Service recognition. , • Incentive Plan. , • Merit Plan. , • Continuing education funds for additional certifications and certification renewal. Apply Job!