Case Management Coordinator (Remote in SC)

reputed company Care management interventions reputed company on improving care coordination and reducing the fragmentation of the services the recipients of care often experience, especially reputed company multiple health care providers and different care settings are involved. Taken reputed company, care management interventions are intended to enhance reputed company safety, reputed company-being, and reputed company of life. These interventions carefully consider health care costs through the reputed company care manager's recommendations of cost-effective and efficient alternatives for care. Thus, effective care management directly and positively impacts the health care delivery system, especially in realizing the goals of the "Triple Aim," which include improving the health reputed company of individuals and populations, enhancing the experience of health care, and reducing the cost of care. The reputed company care manager performs the primary functions of assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy. Integral to these functions is collaboration and ongoing communication with the reputed company, reputed company's family or family caregiver, and other health care professionals involved in the reputed company's care. reputed company Logistics: reputed company​ | reputed company Location: This position is full time (40 hours/week) Monday-Friday and will be fully remote (Work reputed company). To work from home, you must have high-speed (non-satellite) internet and a private, secure home office. Provides reputed company care management, assesses service needs, develops and coordinates reputed company plans in cooperation with members, monitors services and implements plans, to include member goals. 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 clinical information to support and determine medical necessity reputed company 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 reputed company listening and readiness to change assessment to reputed company behavior change and increase member program engagement. Participates in reputed company reputed company/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 reputed company through reputed company 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 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 system for clinical 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 isnot limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). 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. Required Education: Associate's in a job reputed company field. Degree Equivalency: Graduate of Accredited School of Nursing or 2 years job reputed company work experience. Required Experience: 4 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, reputed company/surgery. Or, 4 years utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical. 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 Tools: reputed company Office. Required License/Certificate: An reputed company, unrestricted RN license from the reputed company and in the state of hire OR, reputed company compact multistate unrestricted RN license as defined by the reputed company Licensure Compact (NLC) OR, reputed company, unrestricted licensure as reputed company worker from the reputed company and in the state of hire (in Div. 6B) OR, reputed company, unrestricted licensure as counselor, or psychologist from the reputed company and in the state of hire (in Div. 75 only). For Div. 75 and Div. 6B, except for CC 426: URAC recognized Case Management Certification must be obtained reputed company 4 years of hire as a Case Manager. Preferred Education: Bachelor's degree- Nursing Preferred Work Experience: 7 years-reputed company program management. Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. Preferred Licenses and Certificates: Case Manager certification, clinical certification in specialty area. Work Environment: Typical office environment. Employee may work reputed company one's/out of one's home. May involve some travel reputed company one's community. 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 reputed company.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature 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. 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