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Behavioral Health - Managed Care Coordinator I

Company

BlueCross BlueShield of South Carolina
Address , , Sc
Employment type FULL_TIME
Salary
Expires 2023-07-27
Posted at 11 months ago
Job Description
Summary
Join the Care Management Team of Companion Benefit Alternatives.
Review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions. Utilize clinical proficiency and claims knowledge/analysis to assess, plan, implement, health coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilize available resources to promote quality, cost effective outcomes.

Description

Logistics
This position is full time (40 hours/week) Monday-Friday and will be fully remote (W@H). Must live in South Carolina.
What You Will Do:
  • Utilizes allocated resources to back up review determination.
  • Maintains current knowledge of contracts and network status of all service providers and applies appropriately.
  • Educates internal/external customers regarding medical reviews, medical terminology, coverage determinations, coding procedures, and UM processes, etc. in accordance with contractor guidelines.
  • May provide any of the following in support of utilization review practices: Performs authorization process, ensuring benefit coverage for appropriate medical/pharmacy services based on established Utilization Management guidelines and criteria.
  • Conducts research necessary to make thorough/accurate basis for each determination made.
  • Provides education to members and their families/caregivers.
  • Completes all required training and attends mandatory meetings.
  • Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
  • Supports the discharge planning process by assisting and collaborating with Managed Care Coordinators as appropriate.
  • Identifies and makes referrals to appropriate area/staff (Medical Director, Subrogation, Quality of Care, Case Management, etc.).
  • Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
  • Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
To Qualify for This Position, You Will Need:
  • Good judgment skills.
  • Strong oral and written communication skills.
  • Analytical or critical thinking skills.
  • Working knowledge of word processing software.
  • Demonstrates effective customer service, organizational, and presentation skills.
  • Ability to handle confidential OR sensitive information with discretion.
  • Active, unrestricted RN licensure from the United States and in the state of South Carolina, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LMSW (Licensed Master of Social Work) licensure from the United States and in South Carolina, OR active, unrestricted licensure as Counselor, or Psychologist from the United States and in the state of South Carolina.
  • Microsoft Office.
  • Associate Degree - Nursing OR Graduate of Accredited School of Nursing OR Master's degree in Social Work, Psychology, or Counseling
  • Ability to operate a computer with proficient typing skills.
  • Two years clinical work experience in behavioral health.
What We Prefer:
  • One year of utilization review experience.
  • Ability to work independently, prioritize effectively, and make sound decisions.
  • Persuasive, motivational, and influential.
  • Ability to work with multiple software programs simultaneously with excellent computer skills.
  • Knowledge of Microsoft Excel, Access, OR other database software.
What We Can Do for You
  • On-site cafeterias and fitness centers in major locations
  • Continuing education funds for additional certifications and certification renewal
  • Nine paid holidays
  • Paid annual leave – the longer you work here, the more you earn
  • 401(k) retirement savings plan with company match
  • Wellness programs and healthy lifestyle premium discount
  • Service recognition
  • Tuition assistance
  • Life insurance
  • Incentive Plan
  • Merit Plan
  • Subsidized health plans and free vision coverage
What to Expect Next
After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements.
Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.
If you need special assistance or an accommodation while seeking employment, please e-mail [email protected] or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.