Care Management Quality Coordinator (PA)MCCII
Care Management Quality Coordinator (PA)MCCII
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1 Vacancy
Job Description
Summary
Reviews and evaluates 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. Utilizes clinical proficiency claims knowledge/analysis and 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. Utilizes available resources to promote quality cost effective outcomes.
Description
This position is fulltime (40hours/week) MondayFriday in a typical office environment. You will work an 8hour shift scheduled during our normal business hours 8:00am5:00pm. It may be necessary given the business needs to work occasional overtime. You may be required to travel between buildings. This role is located at 17 Technology Circle Columbia SC 29203.
What Youll 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 onsite reviews. Promotes enrollment in care management programs and/or health and disease management programs.
- 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.
To Qualify For this position Youll Need the Following:
- Required Education: Associates in a jobrelated field.
- Required Experience: 4 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 4 years utilization review/case management/clinical/or combination; 2 of 4 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 Other Tools: Microsoft Office
- Required License/Certificate: Active unrestricted RN licensure 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) OR active unrestricted LMSW (Licensed Master of Social Work) licensure from the United States and in the state of hire OR active unrestricted licensure as Counselor or Psychologist from the United States and in the state of hire.
We Prefer That You Have The Following:
- Preferred Education: Bachelors degree Nursing
- Preferred Work Experience: 7 yearshealthcare program management.
- Preferred Skills and Abilities: Working knowledge of spreadsheet database software. Thorough knowledge/understanding of claims/coding analysis requirements and processes.
- Preferred Software and Other Tools: Working knowledge of Microsoft Excel Access or other spreadsheet/database software.
- Preferred Licenses and Certificates: Case Manager Certification clinical certification in specialty area.
- Work Environment: Typical office environment. Employee may work from home. May involve some travel within ones community.
Our comprehensive benefits package includes the following:
We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.
- Subsidized health plans dental and vision coverage
- 401k retirement savings plan with company match
- Life Insurance
- Paid Time Off (PTO)
- Onsite cafeterias and fitness centers in major locations
- Education Assistance
- Service Recognition
- National discounts to movies theaters zoos theme parks and more
What We Can Do for You:
We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills advance their careers and contribute their unique abilities to the growth of our company.
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 our recruiter to verify resume specifics and salary requirements.
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 individuals with disabilitiesand protected 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 disabilities pregnant individuals individuals with pregnancyrelated conditions and individuals needing accommodations for sincerely held religious beliefs provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment please email or callext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a casebycase basis.
We participate in EVerify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Heres moreinformation.
Some states have required notifications. Heres more information.
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 individuals with disabilitiesand protected 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 disabilities pregnant individuals individuals with pregnancyrelated conditions and individuals needing accommodations for sincerely held religious beliefs provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment please email or callext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a casebycase basis.
We participate in EVerify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Heres moreinformation.
Some states have required notifications. Heres more information.
Required Experience:
IC
Employment Type
Full-Time
