RN Case Management Coordinator (W@H SC)

Summary We are currently hiring for a Case Management Coordinator to join BlueCross BlueShield of South Carolina. In this role as a Case Management Coordinator, care management interventions focus on improving care coordination and reducing the fragmentation of the services the recipients of care often experience, especially when multiple health care providers and different care settings are involved. Taken collectively, care management interventions are intended to enhance client safety, well-being, and quality of life. These interventions carefully consider health care costs through the professional care manager's recommendations of cost-effective and efficient alternatives for care. Thus, effective care management directly and positively impacts the health care delivery system, especially in realizing the goals of the "Triple Aim," which include improving the health outcomes of individuals and populations, enhancing the experience of health care, and reducing the cost of care. The professional care manager performs the primary functions of assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy. Integral to these functions is collaboration and ongoing communication with the client, client's family or family caregiver, and other health care professionals involved in the client's care. Location This position is full-time (40 hours/week) Monday-Friday from 8:00am-5:00pm EST and will be fully remote in South Carolina. The candidate may be required to report on-site for occasional trainings, meetings, or other business needs. What You’ll Do 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. To Qualify for This Position, You’ll Need the Following: Education: Associates in a job-related field. Degree Equivalency: Graduate of Accredited School of Nursing or 2 years job related work experience. Experience: 4 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedics, general medicine/surgery. Or, 4 years utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical. Skills and Abilities: 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. Software and Tools: Microsoft Office. License/Certificate: 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 counselor, or psychologist from the United States and in the state of hire (in Div. 75 only). For Div. 75 and Div. 6B, except for CC 426: URAC recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager. Preferred: Work Experience: 7 years-healthcare program management. Skills and Abilities: Working knowledge of spreadsheet, database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. Licenses and Certificates: Case Manager certification, clinical certification in specialty area. Our Comprehensive Benefits Package Includes the Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits for the first of the month following 28 days of employment. 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. What We Can Do for You We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email View email address on click.appcast.io or call View phone number on click.appcast.io with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Veterans Welcome! BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty. Join Us Join Us If you're ready to join in a diverse company with secure, community roots and an innovative future, #J-18808-Ljbffr Southcarolinablues