Case Coordinator

• 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).

Case Management Coordinator focused on improving care coordination at BlueCross BlueShield.

RN Case Management Coordinator, Maternity/NICU

Case Management Coordinator focused on improving care coordination at BlueCross BlueShield. Responsibilities include care assessments, planning, monitoring services, and advocacy for patients.

• 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

Case Management Coordinator managing care interventions at BlueCross BlueShield.

Case Management Coordinator, Social Worker

Case Management Coordinator controlling care coordination interventions and working on improving service delivery at BlueCross BlueShield.

• 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

Case Management Coordinator focusing on maternity care management at BlueCross BlueShield

Case Management Coordinator, Maternity Focus

Case Management Coordinator focusing on maternity care management at BlueCross BlueShield of South Carolina. Responsible for care coordination and serving as an advocate for clients with chronic conditions.

• 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.

Case Management Coordinator coordinating care for BlueCross BlueShield of South Carolina.

Case Management Coordinator focusing on care management and patient education for BlueCross BlueShield of South Carolina. Ensuring client safety and advocating for member needs through effective communication and coordination.

RN Case Management Coordinator for BlueCross BlueShield of South Carolina

RN Case Management Coordinator – NICU, Maternity

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.

Case Coordinator jobs in South Carolina

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RN Case Management Coordinator, Maternity/NICU

Case Management Coordinator, Social Worker

Case Management Coordinator, Maternity Focus

Case Management Coordinator, Maternity Focus

RN Case Management Coordinator – NICU, Maternity