Managed Care Coordinator I Pharmacy UM
Managed Care Coordinator I Pharmacy UM
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Job Description
Summary
We are currently hiring for a Managed Care Coordinator I to join BlueCross BlueShield of South this role as Managed Care Coordinator I you will be responsible for reviewing and evaluating appropriateness of medication therapy by applying clinical expertise administrative policies and established clinical criteria to prior authorization requests. The individual selected for this position will utilize their clinical proficiency and claim knowledge/analysis to assess and evaluate medical necessities and options for medications to support members in managing their health chronic illness or acute illness. This role will collaborate with other health professionals to ensure that medications prescribed for patients contribute to the best possible health outcomes and value to our members and clients.
Description
Location
This position is full time (40 hours/week) Monday-Friday from 8:00am 5:00pm EST and will be hybrid in Columbia SC.
What Youll Do:
Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Evaluates outcomes of plans eligibility level of benefits place of service length of stay and medical necessity regarding requested services and benefit exceptions. May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
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 patient education with members and providers regarding health care delivery system utilization on networks and benefit plans. Serves as member advocate through continued communication and education. 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.
Provides appropriate communications (written telephone) regarding requested services to both health care providers and members.
To Qualify for This Position Youll Need the Following:
Required Education: Associates in a job-related field.
Degree Equivalency: Graduate of Accredited School of Nursing or 2 years of job-related work experience.
Required Work Experience: 2 years clinical experience.
Required Skills and Abilities: Working knowledge of word processing software.
Ability to work independently prioritize effectively and make sound decisions.
Good judgment skills.
Demonstrated customer service organizational and presentation skills.
Demonstrated proficiency in typing 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.
Required Licenses and Certificates: 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: Prior Pharmacy Utilization Management experience.
Work experience in healthcare program management utilization review or clinical experience in defined specialty. Specialty areas are oncology cardiology neonatology maternity rehabilitation services mental health/chemical dependency orthopedic general medicine/surgery.
Preferred Skills and Abilities: Working knowledge of spreadsheet database software.
Knowledge of contract language and application.
Thorough knowledge/understanding of claims/coding analysis/requirements/processes.
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)
On-site 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 pregnancy-related 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 call 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.
We participate in E-Verify 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
