About this role
Your Role
The Care Management team is a member-facing team that provides care coordination to our most vulnerable members to help them overcome barriers, access appropriate services and resources, and improve their overall health and quality of life. The CSC will connect members with needed resources and provide individualized care coordination based on each member’s identified needs and eligibility for services. The Clinical Service Coordinator, Advanced will report to the Manager of Care Management.
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Work
In this role, you will
- Support nurse case managers and members with escalated cases involving complex care coordination needs, including claims denials, authorization needs, Continuity of Care (COC) requests, and Access to Care (ATC) needs.
- Research member eligibility, benefits, claims history, authorization status, provider networks, and case documentation to help identify barriers and support timely resolution.
- Coordinate with appropriate internal and external partners to support case resolution, including program managers, provider relations, medical directors, provider offices, medical groups, and Blue Shield of California clinical and operational teams.
- Serve as a liaison between nurse case managers, members, providers, and cross-functional stakeholders to help resolve escalated issues and ensure members are connected to appropriate services and resources.
- Track escalated case activity, follow up on outstanding items, document updates, and communicate next steps to support timely closure and continuity of care.
- Demonstrate cultural competence and MI practices while focusing on a member-centered approach when assisting with complex or sensitive member needs.
Your Knowledge and Experience
- Requires a High School diploma or GED or 1 additional year of relevant experience in lieu of a diploma
- Requires 5 years of prior relevant experience
- Desired Certification and/or training as a patient advocate, health coach, care navigator
- Health insurance/managed care experience (Commercial, IFP, Medicare, and Medi-Cal)
- Experience with community resources and advocacy
- Strong interpersonal communication skills and organizational skills
Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.