LPN Utilization Management Coordinator I

001 BlueCross and BlueShield of South Carolina; South Carolina; Hybrid; USD 54,000 - 80,000; Full time

Benefits offered by this job

Subsidized health plans

401k with company match

Life Insurance

Paid Time Off (PTO)

Education Assistance

Job summary

BlueCross BlueShield of South Carolina is hiring a full‑time LPN Utilization Management Coordinator I for a fully remote role with occasional on‑site trainings. Bachelors in a related field plus LPN/LVN licensure and UM experience are required.

You will review medical/pharmacy services for coverage, determine eligibility and medical necessity, educate members, and support discharge planning with care teams. Strong communication and analytical skills are essential.

Qualifications

• Bachelor's in a related field is required.
• 2 years’ LPN/LBSW experience is required.
• Active LPN/LVN license in state of hire or compact multistate license, or active LBSW is required.

Responsibilities

• Perform authorization process, ensuring benefit coverage per Utilization Management guidelines.
• Review eligibility, level of benefits, and medical necessity of services.
• Educate members and families regarding UM processes and implications.
• Collaborate with Managed Care Coordinators to support discharge planning.
• Respond timely with documentation to members and providers on determinations.

Skills

Word processing

Judgment

Customer service

Analytical thinking

Discretion

Typing

Communication

Education

Bachelor's in related field

Tools

Microsoft Office

Job description

Summary

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! We are currently hiring for an LPN Utilization Management Coordinator I to join BlueCross BlueShield of South Carolina. In this role as an LPN Utilization Management Coordinator I, you will perform medical surgical/pharmacy reviews using established criteria sets and/or perform utilization management of services within the LPN/LBSW scope of practice to include but not limited to professional, durable medical equipment, home health services, and/or pharmacy requests covered under the medical plan. You will document decisions using indicated protocol sets or clinical guidelines and provide support and review of medical claims and utilization practices.

Location

This position is full-time (40 hours/week) Monday-Friday from 8:30am – 5:00pm and will be fully remote. The candidate may be required to report on-site for occasional trainings, meetings, or other business needs. Sponsorship: This position is not eligible for sponsorship now or in the future.

What You’ll Do

May provide any of the following in support of utilization review practices:

• Performs authorization process, ensuring benefit coverage for appropriate medical/pharmacy services based on established Utilization Management guidelines and criteria.
• Utilizes allocated resources to back up review determination.
• Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
• Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
• Provides education to members and their families/caregivers.
• Conducts research necessary to make thorough/accurate basis for each determination made.
• Supports the discharge planning process by assisting and collaborating with Managed Care Coordinators as appropriate.
• Educates internal/external customers regarding medical reviews, medical terminology, coverage determinations, coding procedures, and UM processes, etc. in accordance with contractor guidelines.
• Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• Maintains current knowledge of contracts and network status of all service providers and applies appropriately.
• Completes all Required Licenses and Certificates and attends mandatory meetings.
• Identifies and makes referrals to appropriate area/staff (Medical Director, Subrogation, Quality of Care, Case Management, etc.).

To Qualify for This Position, You’ll Need the Following

Required Education

Bachelors in a job-related field

Degree Equivalency

Graduate of Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing.

Required Work Experience

2 years’ working experience as LPN or LBSW.

Required Skills and Abilities

• Working knowledge of word processing software.
• Good judgment skills.
• Demonstrates effective customer service, organizational, and presentation skills.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.
• Ability to operate a computer with proficient typing skills.
• Strong oral and written communication skills.

Required Software and Tools

Microsoft Office.

Required Licenses and Certificates

• Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR active LBSW (licensed Bachelor of Social Work) in state hired.

Preferred Work Experience

1 year of utilization review experience.

Preferred Skills and Abilities

• Ability to work independently, prioritize effectively, and make sound decisions.
• Persuasive, motivational, and influential.

Preferred Software and Tools

Knowledge of Microsoft Excel, Access, or other database software.

Our Comprehensive Benefits Package Includes the Following

• 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.

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 [e-mail] 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.

Welcome

Here’s Your Smart Career Move Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. Business and political climates may change, but we’re stronger than ever. Our A.M. Best rating is A+ (Superior) — making us the only health insurance company in South Carolina with that rating. We’re 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Veterans Welcome! BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty. Join Us If you're ready to join in a diverse company with secure, community roots and an innovative future,