RN Navigator Case Manager – MCC II
BlueCross BlueShield of South Carolina
full-time
Posted on:
Location Type: Hybrid
Location: Miami • Florida • United States
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About the role
- Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals.
- 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.
- Provides telephonic support for members with chronic conditions, high-risk pregnancy or other at-risk conditions.
- Participates in direct intervention/patient education with members and providers regarding health care delivery system.
- May identify, initiate, and participate in on-site reviews.
- Serves as member advocate through continued communication and education.
- Promotes enrollment in care management programs and/or health and disease management programs.
- Provides appropriate communications regarding requested services to both health care providers and members.
- 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.
Requirements
- An active, unrestricted RN license 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)
- Associate Degree - Nursing, OR, Graduate of Accredited School of Nursing
- Four years recent clinical in defined specialty area
- 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 proficiency in spelling, punctuation, and grammar skills
- Ability to persuade, negotiate, or influence others
- Analytical or critical thinking skills
- Ability to handle confidential or sensitive information with discretion
- Microsoft Office proficiency
- URAC recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager
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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
case managementclinical evaluationmedical necessity criteriapatient educationbehavioral reviewquality improvement processescontract language applicationtelephonic supportreferral identificationdocumentation accuracy
Soft Skills
independent workprioritizationdecision makinggood judgmentpersuasionnegotiationanalytical thinkingcritical thinkingdiscretioncommunication
Certifications
RN licenseURAC Case Management Certification