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/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. Description Location This position is full-time (40 hours/week) Monday-Friday from 8:30am – 5:00pm and will be fully remote . The candidate will be required to report on-site for the first 3 days of the job and may be required to come on-site for occasional trainings, meetings, or other business needs. 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 Experience: Prior DME experience. Our Comprehensive Benefits Package Includes the Following: We offer our employees great benefits and rewards.  You will be eligible to participate in the benefits the first of the month following 28 days of employment. 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. What To Expect Next: After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

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