Summary
 

We are currently hiring for a Managed Care Coordinator II/CM-DM to join BlueCross BlueShield of South Carolina. In this role Managed Care Coordinator II/CM-DM, you will review and evaluate medical and/or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests, or provide health management program interventions. You will also utilize clinical proficiency and claims knowledge/analysis; comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity options and services required to support members in managing their health, chronic illness, or acute illness. With this role, you will utilize available resources to promote quality, cost effective outcomes.

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

Description
 

Logistics

This position is full time (40 hours/week) Monday-Friday and will be fully remote (W@H).

What You Will Do:

• Performs medical or behavioral review/authorization process.

• Ensures coverage for appropriate services within benefit and medical necessity guidelines.

• 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).

• Provides discharge planning and assesses service needs in cooperation with providers and facilities.

• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.

• Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.

• Collaborates with BCBSSC Care Management and other areas to ensure proper care management processes are executed within a timely manner.

• Manages assigned members and authorizations through appropriate communication.

• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

• Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.

• May identify, initiate, and participate in on-site reviews.

• Promotes enrollment in care management programs and/or health and disease management p