Facebook · 1 day ago
RN Managed Care Coordinator I - Utilization Management
W@H South Carolina
Full-time
Hybrid
Entry Level
2+ years expBlueCross BlueShield of South Carolina is currently hiring for a Managed Care Coordinator I. In this role, you will review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria, utilizing clinical expertise and administrative policies to support members in managing their health.
Computer Software
Responsibilities
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
Qualification
Required
Associates in a job-related field
Graduate of Accredited School of Nursing or 2 years of job-related work experience
2 years' clinical experience
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
Microsoft Office
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
Preferred
Previous experience working with National Alliance
Bachelor's degree- Nursing
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
Working knowledge of spreadsheet, database software
Knowledge of contract language and application
Thorough knowledge/understanding of claims/coding analysis/requirements/processes
Benefits
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
Company
The Facebook company is now Meta. Meta builds technologies that help people connect, find communities, and grow businesses.
10001+ employees
H1B Sponsorship
Facebook has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2022 (942)
2021 (5811)
2020 (4476)
Funding
Current Stage
Late StageLeadership Team
Arunava Chatterjee
Executive Director of Ghost Black Operations & CEO & CTO
Shubhra Gupta
CEO
Recent News
Business Live
2025-11-03
2025-11-01
Company data provided by crunchbase