Facebook · 3 days ago
Managed Care Coordinator UM II
W@H South Carolina
Full-time
Hybrid
Mid Level
4+ years expBlueCross BlueShield of South Carolina is currently hiring for a Managed Care Coordinator II – Utilization Management. This role involves reviewing and evaluating medical or behavioral eligibility regarding benefits and clinical criteria, utilizing clinical expertise to assess, plan, implement, coordinate, monitor, and evaluate medical necessity and services required for members.
Computer Software
Responsibilities
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 on-site 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
Qualification
Required
Associate's in a job related field
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
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
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
Bachelor's degree- Nursing
7 years-healthcare program management
Working knowledge of spreadsheet, database software
Thorough knowledge/understanding of claims/coding analysis, requirements, and processes
Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software
Case Manager Certification, clinical certification in specialty area
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