Summary Care management interventions focus on improving care coordination and reducing the fragmentation of the services the recipients of care often experience, especially when multiple health care providers and different care settings are involved. Taken collectively, care management interventions are intended to enhance client safety, well-being, and quality of life. These interventions carefully consider health care costs through the professional care manager's recommendations of cost-effective and efficient alternatives for care. Thus, effective care management directly and positively impacts the health care delivery system, especially in realizing the goals of the "Triple Aim," which include improving the health outcomes of individuals and populations, enhancing the experience of health care, and reducing the cost of care. The professional care manager performs the primary functions of assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy. Integral to these functions is collaboration and ongoing communication with the client, client's family or family caregiver, and other health care professionals involved in the client's care. 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: Care management interventions focus on improving care coordination and reducing the fragmentation of the services the recipients of care often experience, especially when multiple health care providers and different care settings are involved. Taken collectively, care management interventions are intended to enhance client safety, well-being, and quality of life. These interventions carefully consider health care costs through the professional care manager's recommendations of cost-effective and efficient alternatives for care. Thus, effective care management directly and positively impacts the health care delivery system, especially in realizing the goals of the "Triple Aim," which include improving the health outcomes of individuals and populations, enhancing the experience of health care, and reducing the cost of care. The professional care manager performs the primary functions of assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy. Integral to these functions is collaboration and ongoing communication with the client, client's family or family caregiver, and other health care professionals involved in the client's care. Location: This is a remote position, from 8:30am to 5pm Monday through Friday. What You’ll Do: - 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. To Qualify For This Position, You'll Need The Following: - Required Education: Associate's in a job related field. - Degree Equivalency: 2 years job related work experience. - Required Experience: 4 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery. Or, 4 years utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical. - 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. Good judgment skills. 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 critical thinking skills. Ability to handle confidential or sensitive information with discretion. - Required Software and Tools: Microsoft Office. - Required License/Certificate: An active, unrestricted RN license 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, unrestricted licensure as social worker from the United States and in the state of hire (in Div. 6B) OR, active, unrestricted licensure as counselor, or psychologist from the United States and in the state of hire (in Div. 75 only). For Div. 75 and Div. 6B, except for CC 426: URAC recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager. We Prefer That You Have The Following: - Preferred Work Experience: 7 years-healthcare program management. 4+ years of Renal/ Nephrology experience. - Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. - Preferred Licenses and Certificates: Case Manager certification, clinical certification in specialty area. 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 plans, dental and vision coverage - 401k retirement savings plan with company match - Life Insurance - Paid Time Off (PTO) - On-site cafeterias and fitness centers in major locations - Education Assistance - Service Recognition - National discounts to movies, theaters, zoos, theme parks and more 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. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.

• Responsible for pre-authorization reviews in accordance with medical contract and regulations • Conduct utilization review and ensure quality of care

Company Overview At Enlyte, we combine innovative technology, clinical expertise, and human compassion to help people recover after workplace injuries or auto accidents. We support their journey back to health and wellness through our industry-leading solutions and services. Whether you're supporting a Fortune 500 client or a local business, developing cutting-edge technology, or providing clinical services you'll work alongside dedicated professionals who share your commitment to excellence and make a meaningful impact. Join us in fueling our mission to protect dreams and restore lives, while building your career in an environment that values collaboration, innovation, and personal growth. Be part of a team that makes a real difference. Job Description This is a full-time, field position, remote when not traveling locally. The candidate must be located in the Naples, FL area due to regular local travel for in-person patient appointments. 60% travel Candidates without a URAC credential will not be considered Perks: Full and comprehensive benefits program, 24 days of paid vacation/holidays in your first year plus sick days, home office equipment including laptop and desktop monitor, mileage and travel reimbursement, Employee Assistance and Referral Program, and hands-on workers’ compensation case management training. Join our compassionate team and help make a positive difference in an injured person’s life. As a Field Case Manager, you will work closely with treating physicians/providers, employers, customers, legal representatives, and the injured/disabled person to create and implement a treatment plan that returns the injured/disabled person back to work appropriately, ensure appropriate and cost-effective healthcare services, achievement of maximum medical recovery and return to an optimal level of work and functioning. In this role, you will: - Demonstrate knowledge, skills, and competency in the application of case management standards of practice. - Use advanced knowledge of types of injury, medications, comorbidities, treatment options, treatment alternatives, and knowledge of job duties to advise on a treatment plan. - Interview disabled persons to assess overall recovery, including whether injuries or conditions are occupational or non-occupational. - Collaborate with treating physicians/providers and utilize available resources to help create and implement treatment plans tailored to an individual patient. - Work with employers and physicians to modify job duties where practical to facilitate early return to work. - Evaluate and modify case goals based on injured/disabled person’s improvement and treatment effectiveness. - Independently manage workload, including prioritizing cases and deciding how best to manage cases effectively. - Complete other duties, such as attend injured worker’s appointments when appropriate, prepare status updates for submittal to customers, and other duties as assigned. Qualifications - Education: Associates Degree or Bachelor’s Degree in Nursing or related field. - Experience: 2+ years clinical practice preferred. Workers’ compensation-related experience preferred. - Skills: Ability to advocate recommendations effectively with physicians/providers, employers, and customers. Ability to work independently. Knowledge of basic computer skills including Excel, Word, and Outlook Email. Proficient grammar, sentence structure, and written communication skills. - Certifications, Licenses, Registrations: - Active Registered Nurse (RN) license required. Must be in good standing. - URAC-recognized certification in case management required (CCM, CDMS, CRC, CVE, CRRN or COHN). - Travel: Must have reliable transportation and be able to travel to and attend in-person appointments with injured workers in assigned geography. - Internet: Must have reliable internet. Benefits We’re committed to supporting your ultimate well-being through our total compensation package offerings that support your health, wealth and self. These offerings include Medical, Dental, Vision, Health Savings Accounts / Flexible Spending Accounts, Life and AD&D Insurance, 401(k), Tuition Reimbursement, and an array of resources that encourage a lifetime of healthier living. Benefits eligibility may differ depending on full-time or part-time status. Compensation depends on the applicable US geographic market. The expected base pay for this position ranges from $70,600 - $85,000 annually. In addition to the base salary, you will be eligible to participate in our productivity-based bonus program. Your total compensation, including base pay and potential bonus, will be based on a number of factors including skills, experience, education, and performance metrics. The Company is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability. Don’t meet every single requirement? Studies have shown that women and underrepresented minorities are less likely to apply to jobs unless they meet every single qualification. We are dedicated to building a diverse, inclusive, and authentic workplace, so if you’re excited about this role but your past experience doesn’t align perfectly with every qualification in the job description, we encourage you to apply anyway. You may be just the right candidate for this or other roles. #LI-VH1 #FCM Registered Nurse (RN), Nursing, Home Care Registered Nurse, Emergency Room Registered Nurse, Clinical Nurse, Nurse Case Manager, Field Case Manager, Medical Nurse Case Manager, Workers’ Compensation Nurse Case Manager, Critical Care Registered Nurse, Advanced Practice Registered Nurse (APRN), Nurse Practitioner, Case Management, Case Manager, Home Healthcare, Clinical Case Management, Hospital Case Management, Occupational Health, Patient Care, Utilization Management, Acute Care, Orthopedics, Rehabilitation, Rehab, CCM, Certified Case Manager, CDMS, Certified Disability Management Specialist, CRC, Certified Rehab Certificate, CRRN, Certified Rehab Registered Nurse, COHN, Certified Occupational Health Nurse, CMC, Cardiac Medicine Certification, CMAC, Case Management Administrator Certification, ACM, Accredited Case Manager, MSW, Masters in Social Work, URAC, Vocational Case Manager

No On-Call Hours, Weekends or Major Holidays. About Belle Belle is a fast growing engagement company that is revolutionizing home healthcare – and it all begins with the feet. With 25M+ U.S. seniors no longer able to see or reach their feet, a lack of self care and mobility challenges cost the health insurance plans $38B+ in preventable medical spending every year. Belle trains and manages a network of nail technicians or “Belle Technicians” who provide in-home foot care (aka medical pedicures). Belle uses cutting edge data science to identify those most in need on behalf of health plans and deploys its services accordingly. While in the home, Belle Technicians complete assessments and screenings, often being the first to identify emerging issues below and above the knee. As these issues arise, a team of remote nurses coordinate care with other healthcare providers - preventing serious and costly episodes. Our mission: Bring Joy to Healthcare. Join us if our cause inspires you! Purpose of this Role Belle is seeking a full-time, remote Telephonic Nurse Case Manager to help deliver high-quality, member-centered care. In this role, you will play a key part in improving clinical outcomes, supporting care coordination, and enhancing satisfaction for both members and their caregivers. As a Nurse Case Manager, you will: - Review documentation from in-home visits - Provide telephonic case management for members - Facilitate and track referrals to appropriate health and community resources - Assess Social Determinants of Health (SDOH) and support the resolution of identified barriers to care - Develop, update, and manage individualized care plans in collaboration with members and their care teams This role is ideal for a compassionate nurse who is experienced in care coordination and chronic disease management, and passionate about improving the health and well-being of members through personalized, holistic support. Responsibilities - Manage, validate, and track all member cases, ensuring timely communication with appropriate healthcare and community resources - Leverage strong people skills to relate to members, show empathy for their situational/clinical circumstances, and seek creative ways to advocate for the member's best interest - Provide feedback on BT documentation - Communicate areas for improvement clearly and constructively to support continuous enhancement of care quality and the member experience Experience, Skills, & Personality - Active Registered Nurse (RN) license with Multi-State Compact Licensure - 2 years of experience in clinical case management - Experience working with older adults - Strong organizational and time management skills - Excellent verbal and written communication skills - Naturally empathetic with strong active listening abilities - Quick-thinking and resourceful problem solver - Passionate about population health and improving outcomes for aging populations - Skilled in coordinating and facilitating timely referrals to appropriate care and community resources - Preferred: - Case management certification - Skilled in motivational interviewing - Bilingual Spanish-speaking - Experience with Google Suite, Slack, CCIQ, eClinicalWorks - Experience working remotely Benefits - Competitive compensation based on experience - Health, Dental, and Vision Insurance Benefits - 401k - PTO, Sick, Wellness leave, and Paid Holidays - Opportunity for significant career growth and expansion of responsibilities - Ability to reshape an industry and protect lives Belle is an Equal Employment Opportunity employer that proudly pursues and hires a diverse workforce. Belle does not make hiring or employment decisions on the basis of race, color, religion or religious belief, ethnic or national origin, nationality, sex, gender, gender-identity, sexual orientation, disability, age, military or veteran status, or any other basis protected by applicable local, state, or federal laws or prohibited by Company policy. Belle also strives for a healthy and safe workplace and strictly prohibits harassment of any kind. This employer conducts post-offer background checks and participates in E-Verify. Belle will provide the federal government with your Form I-9 information to confirm that you are authorized to work in the U.S. If E-Verify cannot confirm that you are authorized to work, this employer is required to give you written instructions and an opportunity to contact Department of Homeland Security (DHS) or Social Security Administration (SSA) so you can begin to resolve the issue before the employer can take any action against you, including terminating your employment. Employers can only use E-Verify once you have accepted a job offer and completed the Form I-9. Belle is an Equal Employment Opportunity employer that proudly pursues and hires a diverse workforce. Belle does not make hiring or employment decisions on the basis of race, color, religion or religious belief, ethnic or national origin, nationality, sex, gender, gender-identity, sexual orientation, disability, age, military or veteran status, or any other basis protected by applicable local, state, or federal laws or prohibited by Company policy. Belle also strives for a healthy and safe workplace and strictly prohibits harassment of any kind. This employer participates in E-Verify and will provide the federal government with your Form I-9 information to confirm that you are authorized to work in the U.S. If E-Verify cannot confirm that you are authorized to work, this employer is required to give you written instructions and an opportunity to contact Department of Homeland Security (DHS) or Social Security Administration (SSA) so you can begin to resolve the issue before the employer can take any action against you, including terminating your employment. Employers can only use E-Verify once you have accepted a job offer and completed the Form I-9.