Managed Care Coordinator I - Pharmacy UM (Columbia)

Managed Care Coordinator I

We are currently hiring for a Managed Care Coordinator I to join BlueCross BlueShield of South Carolina. In this role, you will be responsible for reviewing and evaluating the appropriateness of medication therapy by applying clinical expertise, administrative policies, and established clinical criteria to prior authorization requests. The individual selected for this position will utilize their clinical proficiency and claim knowledge / analysis to assess and evaluate medical necessities and options for medications to support members in managing their health, chronic illness, or acute illness. This role will collaborate with other health professionals to ensure that medications prescribed for patients contribute to the best possible health outcomes and value to our members and clients.

Location : This position is full time (40 hours / week) Monday-Friday from 8 : 00am 5 : 00pm EST and will be hybrid in Columbia, SC.

What You'll Do :

• Performs medical or behavioral review / authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. May initiate / coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• 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).
• Provides patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and / or health and disease management programs.
• 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.
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

To qualify for this position, you'll need the following :

We prefer that you have the following :

Our comprehensive benefits package includes the following :

What We Can Do for You :

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

What To Expect Next :

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

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 individuals with disabilities and protected 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.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

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