UM Coordinator II

BlueCross BlueShield of South Carolina

3d•Remote

About The Position

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! Position Purpose: Performs medical/pharmacy reviews using established criteria sets and/or performs 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. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Assists with discharge planning as appropriate. Serves as a resource, mentor, and preceptor as needed. Location: This is a remote position, but local candidates a preferred. The team works from 8:30am - 5pm.

Requirements

Required Education: Bachelor's 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 and 1 year working experience of utilization management and/or medical/pharmacy reviews.
Required Skills and Abilities: Working knowledge of word processing software. Good judgment skills. Demonstrates effective customer service, organizational, and presentation skills. Analytical and 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. Accurate application of medical policy/guideline criteria. Extensive knowledge of benefits and contracts. Ability to work independently, prioritize effectively, and make sound decisions. Persuasive, motivational, and influential. Demonstrates flexibility in handling multiple tasks. Utilizes available resources effectively and appropriately.
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.

Nice To Haves

Preferred Education: Associate Degree- Nursing.
Preferred Skills and Abilities: Experience educating, training, and/or mentoring new employees. Understanding of claims analysis and processes. Seeks innovative and creative solutions. Participation in quality or process improvement projects or special committees/workgroups.
Preferred Software and Tools: Knowledge of Microsoft Excel, Access, or other database software.

Responsibilities

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.
Identifies and makes referrals to appropriate area/staff (Medical Director, Subrogation, Quality of Care, Case Management, etc.).
Maintains current knowledge of contracts and network status of all service providers and applies appropriately.
Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.
Completes all Required Licenses and Certificates and attends mandatory meetings.
Participates in division or departmental projects and/or serves on special workgroups/committees.