RN Managed Care Coordinator I

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

1d•Remote

About The Position

The RN Managed Care Coordinator I reviews and evaluates medical or behavioral eligibility for benefits and clinical criteria. The role applies clinical expertise, administrative policies, and established criteria to service requests, and uses clinical proficiency and claims knowledge to assess, plan, implement, coordinate, monitor, and evaluate medical necessity and care plan compliance. The coordinator supports members managing chronic or acute illness and promotes quality, cost-effective outcomes. This is a full-time, fully remote position, Monday through Friday, 8:00 a.m. to 5:00 p.m. EST, with occasional onsite attendance possible for training, meetings, or other business needs. The position is not eligible for current or future sponsorship.

Requirements

Associate degree in a job-related field; equivalency may be met by 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.
Demonstrated customer service, organizational, and presentation skills.
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 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. LMSW, 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, 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 or understanding of claims, coding analysis, requirements, and processes.

Responsibilities

Perform medical or behavioral review and authorization processes, ensuring requested services meet benefit coverage and medical necessity guidelines.
Evaluate plan outcomes, eligibility, benefit levels, place of service, length of stay, medical necessity, requested services, and benefit exceptions.
Initiate or coordinate discharge planning or alternative treatment plans when necessary and 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, or 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 regulatory guidelines, including those that may involve ERISA, NCQA, URAC, state DOI, and federal DOL requirements.
Educate members and providers about the health care delivery system, network utilization, and benefit plans; advocate for members through ongoing communication and education.
Promote enrollment in care management and health or disease management programs.
Maintain 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 appropriately with health care providers and members about requested services, in writing and by telephone.