Managed Care II/CM-DM Coordinator (South Carolina)

About the position

The Managed Care Coordinator II/CM-DM at BlueCross BlueShield of South Carolina is responsible for enhancing care coordination and reducing service fragmentation for clients. This role focuses on care management interventions aimed at improving client safety, well-being, and quality of life while considering healthcare costs. The professional care manager will perform assessments, planning, facilitation, coordination, monitoring, evaluation, and advocacy, collaborating with clients, their families, and healthcare professionals to ensure effective care delivery.

Responsibilities

• Provides active care management and assesses service needs.
• Develops and coordinates action plans in cooperation with members.
• Monitors services and implements plans, including member goals.
• Evaluates outcomes of plans, eligibility, level of benefits, and medical necessity regarding requested services.
• Ensures accurate documentation of clinical information to support medical necessity criteria and contract benefits.
• Provides telephonic support for members with chronic conditions or high-risk situations.
• Participates in direct intervention/patient education with members and providers.
• Serves as member advocate through continued communication and education.
• Promotes enrollment in care management and health programs.
• Performs medical or behavioral review/authorization process.
• Ensures coverage for appropriate services within benefit and medical necessity guidelines.
• Identifies and makes referrals to appropriate staff for further assistance.
• Participates in data collection/input for clinical information flow and claims adjudication.
• Demonstrates compliance with applicable legislation and guidelines.

Requirements

• Associates degree in a job-related field or graduate of an accredited school of nursing, or two years of job-related work experience.
• Four years of recent clinical experience in a defined specialty area or four years of utilization review/case management experience, with two years being clinical.
• Working knowledge of word processing software and quality improvement processes.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills and demonstrated customer service, organizational, and presentation skills.
• Demonstrated proficiency in 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.
• Active, unrestricted RN license or equivalent licensure in social work, counseling, or psychology.

Nice-to-haves

• Bachelor's degree in Nursing.
• Seven years of healthcare program management experience.
• Working knowledge of spreadsheet and database software.
• Thorough knowledge of claims/coding analysis and requirements.
• Case Manager certification or clinical certification in a specialty area.

Benefits

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free vision coverage.
• Life insurance.
• Paid annual leave that increases with tenure.
• Nine paid holidays.
• On-site cafeterias and fitness centers in major locations.
• Wellness programs and healthy lifestyle premium discount.
• Tuition assistance for further education.
• Service recognition programs.
• Incentive and merit plans for performance.
• Continuing education funds for certifications and renewal.