Behavioral Health Case Manager II

BlueCross BlueShield of South Carolina•Columbia, SC

2d•Remote

About The Position

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. This is a remote position, but we do prefer local to the South Carolina area. The typical hours are Monday - Friday 8:30am - 5pm.

Requirements

Associate's in a job related field.
2 years job related work 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.
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.
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.

Nice To Haves

Masters degree in Social Work, Psychology, or Counseling.
Prior Experience working in healthcare insurance.
Prior experience within Psych or Behavioral Health.
Case Manager certification, clinical certification in specialty area.
Licensed Master of Social Work.

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.