Summary

Description

Logistics:

• This position is full time (40 hours/week) Monday-Friday, 8:00 am – 5:00 pm.
• It will be work from home following one week of onsite training. To work from home, you must have high-speed internet (non-satellite) and a private home office.
• First week of training will be onsite in Columbia S.C.
• Must be able to travel to the Columbia, SC office occasionally throughout the year. Therefore, preferred candidates will live within a two-hour drive of Columbia, S.C.

• Provides active care management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals. 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. Provides telephonic support for members with chronic conditions, high-risk pregnancy or other at-risk conditions that consist of: intensive assessment/evaluation of condition, at-risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement.
• 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. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs.
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
• 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).
• Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.

• Required License/Certificate: An active, unrestricted RN license from the United States and in the state of hire OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC). URAC recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager.
• Required Education: Associate's in a job related field OR graduate of Accredited School of Nursing.
• Required Experience: Four years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery; OR four years utilization review/case management/clinical or combination, two of the four years must be clinical.
• Required Skills and Abilities: Working knowledge of word processing software. Knowledge of quality improvement processes and demonstrated ability with these activities. Knowledge of contract language and application. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. 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.
• Required Software and Tools: Microsoft Office.

• Recent hospital nursing experience.
• Case management, medical review, utilization review, home health, Hospice and/or Oncology experience.
• URAC recognized Case Management Certification.
• Excellent computer skills, including working between multiple programs simultaneously.

• 401(k) retirement savings plan with company match
• Subsidized health plans and free vision coverage
• Life insurance
• Paid annual leave — the longer you work here, the more you earn
• Nine paid holidays
• On-site cafeterias and fitness centers in major locations
• Wellness programs and a healthy lifestyle premium discount
• Tuition assistance
• Service recognition

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Some states have required notifications. Here's

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. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.