RN Case Management Coordinator – NICU, Maternity

BlueCross BlueShield of South Carolina

RN Case Management Coordinator focusing on care coordination for BlueCross BlueShield of South Carolina. Enhancing client safety and well-being through effective care management interventions.

Posted 6/30/2026full-timeSouth Carolina • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

Provides active care 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 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 reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement.
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.
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 (written, telephone) 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 (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).
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.

Requirements

What you’ll need

Associates in a job related field
2 years job related work experience
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.
4 years utilization review/case management/clinical/or combination; 2 of the 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.
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) OR, active, unrestricted licensure as social worker from the United States and in the state of hire (in Div. 6B) OR, active, unrestricted licensure as counselor, or psychologist from the United States and in the state of hire (in Div. 75 only).
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

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Applicant Tracking System Keywords

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Hard Skills & Tools

Care ManagementClinical AssessmentDocumentation of Clinical InformationBehavioral ReviewData CollectionContract Language KnowledgeMedical Necessity EvaluationTelephonic SupportMember-Centered CoachingClaims Adjudication

Soft Skills

Good JudgmentOrganizational SkillsPresentation SkillsAnalytical ThinkingCommunication Skills

Certifications

URAC Case Management CertificationActive RN LicenseActive Social Worker LicenseActive Counselor LicenseActive Psychologist License