Why should you join the BlueCross BlueShield 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:

• MAX PAY RATE - $38.00/HR.
• CONTRACT TO HIRE.
• 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 
• Work Schedule/Hours:  Monday thru Friday, 8 AM - 4:30 PM - 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.
• MS Teams Interview with Program Manager.
• Must be an RN, live in SC and have an active SC nursing license. 
• Appeals and reconsideration experience preferred.
• Utilization management experience preferred.
• Prior experience working for a health insurance company and/or with Medicare population.
• Flexibility, dependability- we are often called to assist other depts. 
• Strong analytical stills,  Each case is a puzzle that needs to be put together,  not an a,b,c checklist.  
  Knowledge of MS Office (Outlook, Teams, Excel) and able to learn and work out of multiple other systems simultaneously. 
• Ability to work independently.
• Self-driven to accomplish a productivity goal without constant direction.

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 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). 
• 10% 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. 
• 5% 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. 
• 5% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members. 

Required Skills and Abilities: 

• Required Education: Associate degree - Nursing, OR, Graduate of Accredited School of Nursing, OR, Master's degree in Social Work (for Div. 6B or Div. 75) OR Master's in Psychology, or Counseling (for Div. 75 only). 
• Required Experience: 4 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery. Or, 4 years utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical. Required 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 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). 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 Education: Bachelor's degree- Nursing.
• Preferred Work Experience: 7 years-healthcare program management. 
• Preferred Licenses and Certificates: Case Manager certification, clinical certification in specialty area.
• 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. 
• Required Software and Tools: Microsoft Office. 

Preferred Skills and Abilities: 

• Working knowledge of spreadsheet, database software. 
• Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. 
• Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software. 
• Work Environment: Typical office environment. 
• Employee may work form one's/out of one's home. 
• May involve some travel within one's community.

This is the pay range that Magnit reasonably expects to pay someone for this position is $32.00/hour - $38.00/hour. Benefits: Medical, Dental, Vision, 401K (provided minimum eligibility hours are met).

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. If you're ready to join in a diverse company with secure, community roots and an innovative future, apply for a position now!