Coordinator, Managed Care I - Behavioral Health/ Substance Abuse focused

BlueCross BlueShield of South Carolina

5d•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. 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.

Requirements

Associate's in a job related field.
Graduate of Accredited School of Nursing or 2 years job related work experience .
2 years clinical experience.
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.
Microsoft Office.
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), OR, active, unrestricted LMSW (Licensed Master of Social Work) licensure from the United States and in the state of hire, OR active, unrestricted licensure as Counselor, or Psychologist from the United States and in the state of hire.

Nice To Haves

Bachelor's degree- Nursing.
work experience in 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.

Responsibilities

Performs medical or behavioral review/authorization process.
Ensures coverage for appropriate services within benefit and medical necessity guidelines.
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 plans 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). 1Provides 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.
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.