Find More Than 10K+
United Kingdom Jobs

We are currently hiring for a Managed Care Coordinator I to join BlueCross BlueShield of South Carolina. In this role Managed Care Coordinator I, 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, plan, implement, health coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, and 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.

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. We are 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!

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

• Performs medical or behavioral review/authorization process.
• Ensures coverage for appropriate services within benefit and medical necessity guidelines.
• Assesses service needs, develops, and coordinates action plans in cooperation with members, monitors services and implements plans.
• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• May initiate/coordinate discharge planning or alternative treatment plan as necessary and appropriate.
• Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• 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).
• Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.
• Serves as member advocate through continued communication and education.
• Promotes enrollment in care management programs and/or health and disease management programs.
• 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.
• 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.

• Active, unrestricted RN licensure 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).
• Associate Degree – Nursing, OR Graduate of Accredited School of Nursing.
• Two years of clinical experience as a Registered Nurse.
• Attention to detail.
• Microsoft Office.

• Bachelor's degree – Nursing.
• Seven years’ healthcare program management, utilization review, OR clinical experience in defined specialty.
• Specialty areas are oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery.
• Working knowledge of spreadsheet, database software.
• Knowledge of contract language and application.
• Thorough knowledge/understanding of claims/coding analysis/requirements/processes.
• Working knowledge of Microsoft Excel, Access, OR other spreadsheet/database software.

• 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.