RN Managed Care Coordinator I

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

1d•Remote

About The Position

BlueCross BlueShield of South Carolina is hiring a Managed Care Coordinator I to review medical or behavioral eligibility for benefits and clinical criteria. The role applies clinical expertise, administrative policies, and established criteria to service requests. It uses clinical proficiency and claims knowledge to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, care plan compliance, options, and services that support members managing chronic or acute illness. The coordinator uses available resources to promote quality, cost-effective outcomes. This is a full-time, 40-hour-per-week position, Monday through Friday, 8:00 a.m. to 5:00 p.m. EST. The role is fully remote in South Carolina.

Requirements

Associate degree in a job-related field; alternatively, graduation from an accredited school of nursing or two years of job-related work experience.
Two years of clinical experience.
Working knowledge of word processing software.
Ability to work independently, prioritize effectively, and make sound decisions.
Good judgment.
Customer service, organizational, and presentation skills.
Proficiency in typing, spelling, punctuation, and grammar.
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 or experience with the software and tools listed.
One of the following active, unrestricted U.S. licenses: RN license in the state of hire; compact multistate RN license as defined by the Nurse Licensure Compact; LMSW license in the state of hire; or Counselor or Psychologist license in the state of hire.

Nice To Haves

Bachelor’s degree in nursing.
Experience in healthcare program management, utilization review, or clinical work in a defined specialty, including oncology, cardiology, neonatology, maternity, rehabilitation services, mental health or chemical dependency, orthopedics, or general medicine/surgery.
Working knowledge of spreadsheet and database software.
Knowledge of contract language and its application.
Thorough knowledge or understanding of claims, coding analysis, requirements, and processes.

Responsibilities

Perform medical or behavioral reviews and authorizations, ensuring services meet benefit and medical-necessity guidelines.
Evaluate plan outcomes, eligibility, benefit levels, place of service, length of stay, medical necessity, and requests for benefit exceptions.
Initiate or coordinate discharge planning or alternative treatment plans when appropriate.
Document clinical information accurately to support medical-necessity determinations and contract benefits.
Use allocated resources to support review determinations and refer cases to appropriate staff, such as Medical Directors, Case Managers, Preventive Services, Subrogation, and Quality of Care Referrals.
Participate in clinical data collection and system input to support information flow and proper claims adjudication.
Comply with applicable legislation and requirements of regulatory bodies, including ERISA, NCQA, URAC, state DOI, and federal DOL, as applicable.
Educate members and providers about the health care delivery system, network utilization, and benefit plans; advocate for members through continued communication and education.
Promote enrollment in care management and health and disease management programs.
Maintain current knowledge of provider contracts and network status and apply that knowledge appropriately.
Assist with claims information, discussion, or resolution and refer issues to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.
Communicate about requested services in writing and by telephone to health care providers and members.