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RN Navigator Case Manager – MCC II
BlueCross BlueShield of South CarolinaRN Navigator Case Manager performing case management in Miami, Florida with emphasis on improving care coordination. Engaging members and providers for optimal health outcomes while ensuring adherence to medical necessity guidelines.
About the role
Key responsibilities & impact- 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
What you’ll need- 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
Comp & perks- 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
ATS Keywords
✓ Tailor your resumeApplicant 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