RN Managed Care Coordinator I

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

4d•Remote

About The Position

BlueCross BlueShield of South Carolina is hiring a Managed Care Coordinator I to review medical or behavioral health eligibility against benefit and clinical criteria. The coordinator applies clinical expertise, administrative policies, and established clinical criteria to service requests, using clinical proficiency and claims knowledge to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, care plan compliance, and services that support members managing acute or chronic health conditions. The role uses available resources to promote quality, cost-effective outcomes. This is a full-time, fully remote position in South Carolina, scheduled Monday through Friday, 8:30 a.m. to 5:00 p.m. Eastern Time, for 40 hours per week. The coordinator conducts medical or behavioral reviews and authorizations, supports appropriate service coverage within benefit and medical-necessity guidelines, and communicates with members and providers. The role also promotes member education and care-management participation, maintains knowledge of contracts and provider networks, supports claims resolution, and follows applicable regulatory requirements.

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 skills.
Demonstrated customer-service, organizational, and presentation skills.
Demonstrated proficiency in typing, 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 proficiency.
One of the following active, unrestricted U.S. credentials, valid in the state of hire where applicable: RN licensure in the state of hire; compact multistate RN licensure as defined by the Nurse Licensure Compact; LMSW licensure in the state of hire; or counselor or psychologist licensure in the state of hire.

Nice To Haves

Bachelor's degree in Nursing.
Work experience in healthcare program management, utilization review, or clinical experience in a defined specialty such as 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 and understanding of claims, coding analysis, requirements, and processes.

Responsibilities

Perform medical or behavioral reviews and authorization processes, ensuring appropriate coverage under benefit and medical-necessity guidelines.
Evaluate care-plan outcomes, eligibility, benefit levels, place of service, length of stay, medical necessity, and benefit exceptions for requested services.
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 information data collection and system input to support information flow and proper claims adjudication.
Comply with applicable legislation and regulatory guidelines, including those that may apply from ERISA, NCQA, URAC, state DOI, and federal DOL.
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- or disease-management programs.
Maintain current knowledge of provider contracts and network status and apply that knowledge appropriately.
Assist with claims information, discussion, and resolution, referring issues to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.
Communicate appropriately in writing and by telephone with health care providers and members about requested services.