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.
65% Directs day-to-day, high-touch member management to include implementation of program goals, coordination of treatment plans, and benefits 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 (i.e. ICU, Palliative Care, Hospice, or Home Health)
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.
Telecommuting is allowed.
Internal Number: R1009909
About BlueCross BlueShield of South Carolina
When you hear "BlueCross BlueShield of South Carolina," you'll see people nodding in recognition. Most everyone knows who we are. As the only South Carolina-owned and operated health insurance carrier, we have been offering security to Palmetto State citizens for more than 70 years. We are also one of South Carolina's largest employers.
Our financial stability is on record. In December 2019, AM Best reaffirmed our A.M. Best rating of A+ (Superior) — making us the only health insurance company in South Carolina with that rating. One of the few companies nationwide to achieve this distinction, this year also marks the 18th consecutive year that S.C. BlueCross met this high standard. For the latest ratings, access www.AMBest.com.
We offer the largest provider networks in the state, offering members the greatest choice in doctors, hospitals and other health care providers.
Our extensive menu of health plans, discounts, added values and online services means more choices for our members, with plans to fit every budget and lifestyle.
What you may not know is just how diverse our company is. Included in our family of companies is BlueChoice® HealthPlan of South Carolina, our managed... care subsidiary, which also includes Healthy BlueSM, our Medicaid health plan. BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.
But there is also a lot more to us than health insurance. We have many affiliated companies that are not licensed with the Blue Cross and Blue Shield Association. These companies are located in South Carolina, Georgia, Ohio, Tennessee and Texas. Some offer other insurance products, such as life insurance and behavioral health benefits and administration. Others administer contracts for the federal government. Some even focus on technology.
BlueCross is also a major supporter of community and charitable causes. We support health care-related research, education and service in South Carolina through the BlueCross BlueShield of South Carolina Foundation.
We're BlueCross BlueShield of South Carolina.