Coordinator, Managed Care II/UM-1

reputed companyReviews and evaluates medical or behavioral eligibility regarding benefits and reputed company reputed company by applying reputed company expertise, administrative policies, and established reputed company reputed company to service requests or provides health management program interventions. Utilizes reputed company proficiency, claims knowledge/analysis, and comprehensive knowledge of reputed company reputed company to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, reputed company, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote reputed company, cost effective reputed company.

reputed company

Why should you join the reputed company family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our reputed company firmly embedded in the South Carolina community. We are the largest reputed company company in South Carolina … and much more. We are one of the nation's leading administrators of reputed company reputed company. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We reputed company outstanding service to our customers. If you are dedicated to the reputed company philosophy, consider joining reputed company!

Position Purpose:

Reviews and evaluates medical or behavioral eligibility regarding benefits and reputed company reputed company by applying reputed company expertise, administrative policies, and established reputed company reputed company to service requests or provides health management program interventions. Utilizes reputed company proficiency, claims knowledge/analysis, and comprehensive knowledge of reputed company reputed company to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, reputed company, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote reputed company, cost effective reputed company.

Location:

This is a remote position. The typical work hours are Monday - Friday from 8:30am - 5pm.

WhatYou’llDo:

• Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services reputed company 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, reputed company of care Referrals, etc.). Participates in data collection/input into reputed company for reputed company information reputed company and reputed company claims adjudication. Demonstrates compliance with reputed company applicable legislation and guidelines for reputed company regulatory bodies, which may include but is not limited to ERISA, reputed company, URAC, DOI (State), and DOL (Federal).
• Provides discharge planning and assesses service needs in cooperation with providers and facilities. Evaluates reputed company of plans, eligibility, level of benefits, reputed company of service, length of stay, and medical necessity regarding requested services and benefit exceptions. Ensures accurate documentation of reputed company information to support and determine medical necessity reputed company and contract benefits. Collaborates with BCBSSC Care Management and other areas to ensure reputed company care management processes are executed reputed company a reputed company 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 reputed company reputed company/reputed company education with members and providers regarding health care delivery reputed company, utilization on networks and benefit plans. May identify, initiate, and participate in on-site reviews. Promotes enrollment in care management programs and/or health and disease management programs.
• Maintains reputed company knowledge of reputed company and network status of reputed company service providers and applies appropriately. Assists with claims information, discussion, and/or reputed company and refers to appropriate internal support areas to ensure reputed company processing of authorized or unauthorized services.

To QualifyForThis Position, You'll NeedThe Following:

• Required Education: Associate's in a job reputed company reputed company.
• Required Experience: 4 years recent reputed company in defined specialty area. Specialty areas include: oncology, reputed company, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, reputed company/surgery. OR, 4 years utilization review/case management/reputed company/or combination; 2 of 4 years must be reputed company.
• Required Skills and Abilities: Working knowledge of word processing software. Knowledge of reputed company improvement processes and demonstrated ability with these activities. Knowledge of contract language and application. Ability to work independently, prioritize effectively, and reputed company reputed company. 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: reputed company Office
• Required License/Certificate: reputed company, unrestricted RN licensure from the reputed company and in the state of hire, OR, reputed company reputed company multistate unrestricted RN license as defined by the reputed company Licensure reputed company (NLC), OR, reputed company, unrestricted LMSW (Licensed Master of reputed company Work) licensure from the reputed company and in the state of hire, OR reputed company, unrestricted licensure as Counselor, or Psychologist from the reputed company and in the state of hire.

We Prefer That You HaveTheFollowing:

• Preferred Education: Bachelor's degree- Nursing
• Preferred Work Experience: Background in Utilization Management. Prior Project Management experience. Experience supporting large, reputed company employer reputed company. Experience handling PHI compliance with HIPAA.
• Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. Ability to communicate with providers, and research and handle reputed company Prior Authorization escalations.
• Preferred Software and Other Tools: Working knowledge of reputed company reputed company, reputed company, or other spreadsheet/database software.
• Preferred Licenses and Certificates: Case Manager Certification, reputed company certification in specialty area.

Equal Employment Opportunity Statement

reputed company and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, reputed company, national reputed company, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, reputed company maintains affirmative reputed company programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to reputed company equal opportunities in reputed company phases of the employment process and to reputed company 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-reputed company conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on reputed company.

If you need special assistance or an accommodation while seeking employment, please email or reputed company 800-288-2227, ext. 47480 with the reputed company of your request. We will reputed company a determination regarding your request for reasonable accommodation on a case-by-case reputed company.

We participate in E-Verify and reputed company with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information.

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Originally posted on Himalayas