RN Managed Care Coordinator I

About the role

We are currently hiring for a Managed Care Coordinator I to join BlueCross BlueShield of South Carolina. In this role as Managed Care Coordinator I, you will review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests. Utilizes clinical proficiency and claims knowledge/analysis to assess, plan, implement, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, 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. Location This position is full time (40 hours/week) Monday-Friday from 8:30am - 5:00pm EST and will be fully remote. The candidate must reside at least 3 hours from Columbia, SC as they will be required to report on-site occasionally for trainings, meetings, or other business needs.

Responsibilities

• 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.
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
• To Qualify for This Position, You'll Need the Following:
• Required Education: Associates in a job-related field.
• Degree Equivalency: Graduate of Accredited School of Nursing or 2 years of job-related work experience.
• Required Work Experience: 2 years' clinical experience.
• Required Skills and Abilities: Working knowledge of word processing software.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills.
• Demonstrated customer service, organizational, and presentation skills.
• Demonstrated proficiency in typing, 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.
• We Prefer That You Have the Following:
• Preferred Education: Bachelor's degree- Nursing.
• Preferred Skills and Abilities: Working knowledge of spreadsheet, database software.
• Knowledge of contract language and application.
• Thorough knowledge/understanding of claims/coding analysis/requirements/processes.
• Our Comprehensive Benefits Package Includes the Following:
• We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 day

Benefits

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