LPN Utilization Management Coordinator I

BlueCross BlueShield of South Carolina•W@H South Carolina, SC

2d•Remote

About The Position

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.

Requirements

Bachelors in a job-related field
Graduate of Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing.
2 years’ working experience as LPN or LBSW.
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.
Microsoft Office.
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.

Nice To Haves

1 year of utilization review experience.
Ability to work independently, prioritize effectively, and make sound decisions.
Persuasive, motivational, and influential.
Knowledge of Microsoft Excel, Access, or other database software.

Responsibilities

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.).