Job Description
Summary Provides care management services to more than 2 million members in South Carolina and nationally.Administers complex, high-touch concierge case management for members identified into specialized programs such as high-risk maternity, NICU, ESRD, Cancer, Palliative Care or Behavioral Health.Identifies risks and provides outreach services to facilitate the coordination of healthcare services and gap closure.Provides individualized care plans to ensure cost-effectiveness, overall care satisfaction, and improved quality of life.Description Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community.We are the largest insurance company in South Carolina and much more.We are one of the nation's leading administrators of government contracts.We operate one of the most sophisticated data processing centers in the Southeast.We also have a diverse family of subsidiary companies, allowing us to build on various business strengths.We deliver outstanding service to our customers.If you are dedicated to the same philosophy, consider joining our team! Position Purpose:Provides care management services to more than 2 million members in South Carolina and nationally.Administers complex, high-touch concierge case management for members identified into specialized programs such as high-risk maternity, NICU, ESRD, Cancer, Palliative Care or Behavioral Health.Identifies risks and provides outreach services to facilitate the coordination of healthcare services and gap closure.Provides individualized care plans to ensure cost-effectiveness, overall care satisfaction, and improved quality of life.What You'll Do:Directs day-to-day, high-touch member management to include implementation of program goals, coordination of treatment plans and benefit coordination for high-risk patient populations and/or those with complex conditions.Coordinates clinical services with external sources to include:providers, vendors, facilities, social workers/case managers and/or community services.Participates in team training and continuing medical education.Prepares for external audits and quality assurance efforts.To Qualify For This Position, You'll Need The Following:Required Education:Associate's degree in Nursing OR Graduate of Accredited School of Nursing OR Master's degree in Social Work, Psychology, or Counseling (Div.75 and 6B) only.Required Work Experience:5 years' case management experience as a RN or 2 years' case manager experience as a RN in a health insurance environment.Required Skills and Abilities: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.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 creative thinking skills.Ability to handle confidential or sensitive information with discretion.Required Software and Tools:Microsoft Office Required Licenses and Certificates: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 licensure as a social worker, psychologist, or counselor in state of hire (Div.75 only).Nationally recognized Case Management certification to be obtained within 2 years of hire as a Case Manager.We Prefer That You Have The Following:Preferred Education:Bachelor's degree in health-related field (Nursing, Healthcare Administration, Pharmacy, Sciences, Applied Health) Preferred Degree Equivalency:Preferred Work Experience:5 years' experience in case management in a sub-specialty area (i.e.ICU, Palliative Care, Hospice, or Home Health) Preferred Skills and Abilities:Strong communication and customer services skills.Excellent analytical skills to problem solve and remedy issues immediately.Ability to work in an autonomous environment or leadership capacity.Preferred Software and Tools:Working knowledge of Microsoft Word, PowerPoint, Excel, or other spreadsheet/database software TMCS, MDDS, and BlueVue.Preferred Licenses and Certificates:Case manager certification, clinical certification in specialty area.Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS) certification.Our Comprehensive Benefits Package Includes The Following:We offer our employees great benefits and rewards.You will be eligible to participate in the benefits the first of the month following 28 days of employment.Subsidized health