Summary
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.
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.