Case Management Coordinator - Oncology Focus

BlueCross BlueShield of South Carolina•W@H South Carolina, SC

4d•Remote

About The Position

The Case Management Coordinator provides care management focused on improving care coordination, reducing fragmentation across providers and care settings, and supporting client safety, well-being, and quality of life. The role considers cost-effective and efficient care alternatives and contributes to improved health outcomes, better care experiences, and lower costs. Core care management functions include assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy, in collaboration and ongoing communication with members, their families or caregivers, and other health care professionals. This is a full-time remote position with a Monday–Friday schedule of either 8:00 a.m.–4:30 p.m. or 8:30 a.m.–5:00 p.m. The position provides active care management, including assessment of service needs, development and coordination of action plans with members, monitoring and implementation of plans, and evaluation of outcomes, eligibility, benefits, place of service, length of stay, medical necessity, and benefit exceptions. It provides telephonic support and member-centered coaching for people with chronic conditions, high-risk pregnancies, and other at-risk conditions. The coordinator supports members and providers through education about health care delivery, provider networks, and benefit plans; communicates decisions and requested-service information; performs medical or behavioral review and authorization; documents clinical information; and helps ensure services meet benefit and medical-necessity guidelines. The role also makes referrals, supports claims processing and resolution, maintains knowledge of contracts and provider networks, and follows applicable regulatory requirements. An active, unrestricted qualifying nursing, social work, counseling, or psychology license is required, depending on division and eligibility criteria.

Requirements

Associate degree in a job-related field, or graduation from an accredited school of nursing, or two years of job-related work experience as a degree equivalency.
Four years of recent clinical experience in a defined specialty area, such as oncology, cardiology, neonatology, maternity, rehabilitation services, mental health or chemical dependency, orthopedics, or general medicine/surgery; alternatively, four years in utilization review, case management, clinical work, or a combination, with at least two years of clinical experience.
Working knowledge of word-processing software.
Knowledge of quality-improvement processes and demonstrated ability with these activities.
Knowledge of contract language and its application.
Ability to work independently, prioritize effectively, and make sound decisions, with good judgment.
Demonstrated customer-service, organizational, and presentation skills.
Demonstrated proficiency in spelling, punctuation, and grammar.
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 skills.
An active, unrestricted U.S. RN license in the state of hire, an active compact multistate unrestricted RN license under the Nurse Licensure Compact, or an active, unrestricted U.S. social worker license in the state of hire for Division 6B, or an active, unrestricted U.S. counselor or psychologist license in the state of hire for Division 75.
For Division 75 and Division 6B, except CC 426, obtain a URAC-recognized Case Management Certification within four years of hire as a Case Manager.

Nice To Haves

Bachelor’s degree in Nursing.
Three or more years of oncology experience.
Working knowledge of spreadsheet and database software.
Thorough knowledge or understanding of claims and coding analysis, requirements, and processes.
Case Manager certification.
Clinical certification in a specialty area.

Responsibilities

Provide active care management by assessing service needs and developing and coordinating action plans with members.
Monitor services, implement plans that include member goals, and evaluate outcomes, eligibility, benefit levels, place of service, length of stay, medical necessity, and benefit exceptions.
Provide telephonic support to members with chronic conditions, high-risk pregnancies, or other at-risk conditions, including intensive assessment, tailored education, and member-centered coaching using motivational interviewing, reflective listening, and readiness-to-change assessment.
Educate and intervene with members and providers regarding the health care delivery system, provider networks, and benefit plans.
Serve as a member advocate through continued communication and education, and promote enrollment in care management and health or disease management programs.
Provide written and telephone communications to members and health care providers regarding requested services.
Perform medical or behavioral review and authorization processes and ensure coverage aligns with benefit and medical-necessity guidelines.
Document clinical information accurately to support medical-necessity determinations and contract benefits, and participate in data collection and system input for clinical information flow and claims adjudication.
Use allocated resources to support review determinations and refer cases to appropriate staff, including Medical Directors, Case Managers, Preventive Services, Subrogation, and Quality of Care Referrals.
Comply with applicable legislation and regulatory guidelines, including those that may apply from ERISA, NCQA, URAC, state DOI, and federal DOL.
Maintain current knowledge of contracts and provider network status and apply that knowledge appropriately.
Assist with claims information, discussion, and resolution, referring matters to internal support areas to help ensure proper processing of authorized or unauthorized services.
Identify, initiate, and participate in on-site reviews as needed.