Internal Reference Number: R1014518
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, Palliative Care 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
65% 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.
20% Coordinates clinical services with external sources to include: providers, vendors, facilities, social workers/case managers and/or community services.
10% Participates in team training and continuing medical education.
5% Prepares for external audits and quality assurance efforts.
- Associate's degree in Nursing OR
- Graduate of Accredited School of Nursing.
- Bachelor's degree in a health-related field (Nursing, Healthcare Administration, Pharmacy, Sciences, Applied Health)
Required Work Experience:
- Five years' experience in case management.
Preferred Work Experience:
- Five years' experience in case management in a sub-specialty area
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.
Preferred Skills and Abilities:
- Strong communication and customer service skills.
- Excellent analytical skills to problem solve and remedy issues immediately.
- Ability to work in an autonomous environment or leadership capacity.
Required Software and Tools:
Preferred Software and Tools:
- Working knowledge of Microsoft Word, PowerPoint, Excel, or other spreadsheet/database software; TMCS, LiveOps, MDDS, and BlueVue.
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).
- Nationally recognized Case Management certification to be obtained within 2 years of hire as a Case Manager.
Preferred Licenses and Certificates:
- Case manager certification, clinical certification in a specialty area.
- Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS) certification.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
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