LPN Utilization Management Coordinator I

001 BlueCross and BlueShield of South Carolina; South Carolina; Hybrid; USD 42,000 - 56,000; Full time

Benefits offered by this job

Subsidized health plans

Dental and vision coverage

401k retirement savings plan with公司匹配

Life Insurance PTO

On-site cafeterias and fitness centers

Education Assistance Service

National discounts to movies, theaters

Job summary

BlueCross BlueShield of South Carolina seeks an Utilization Management Coordinator I to perform medical/pharmacy reviews and manage utilization within LPN/LBSW scope. The role includes documenting decisions, supporting medical claims review, and ensuring compliant UM practices.

The position is full-time, remote in South Carolina, and offers education, training, and benefits as part of a comprehensive package.

Qualifications

• Bachelor's degree or equivalent in a related field.
• Licensed Practical Nursing (LPN) or Licensed Vocational Nursing (LVN) licensure is required.
• 2 years’ working experience as LPN or LBSW.
• Working knowledge of word processing software.
• Strong judgment and decision-making abilities.
• Effective customer service, organizational and presentation skills.
• Analytical or critical thinking abilities.
• Ability to handle confidential information with discretion.
• Typing proficiency and computer literacy.
• Strong oral and written communication skills.
• Microsoft Office proficiency is required.
• Active, unrestricted LPN/LVN licensure or active LBSW in the state hired.

Responsibilities

• Perform authorization and utilization management reviews following guidelines.
• Use allocated resources to back up review determinations.
• Review interdepartmental requests and medical information promptly.
• Determine eligibility, benefits level, and medical necessity of services.
• Educate members and families on medical reviews and UM processes.
• Research to support each determination.
• Support discharge planning and collaborate with care coordinators.
• Communicate documentation to members/providers clearly and timely.
• Maintain up-to-date knowledge of contracts and provider networks.
• Identify referrals to appropriate areas (Medical Director, Subrogation, etc.).

Skills

Word processing

Customer service

Organizational skills

Presentation skills

Analytical thinking

Critical thinking

Discretion/Confidentiality

Typing

Oral and written communication

Education

Bachelor's degree in a job-related field

Graduate of Accredited School of LPN/LVN

Active LPN/LVN licensure (US, state hired) or compact multistate LPN

Active LBSW in state hired

Tools

Microsoft Office

Job description

Summary

We are currently hiring for a Utilization Management Coordinator I to join BlueCross BlueShield of South Carolina. In this role as a 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 remote in South Carolina.

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.

We Prefer That You Have the Following

• 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. Here’s more information. Some states have required notifications. Here’s more information.

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.