LPN Utilization Management Coordinator

🔥 16 hours ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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BlueCross BlueShield of South Carolina

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1946

🏥 Healthcare

💼 Consulting

⚖️ Legal

Healthcare • Consulting • Legal

BlueCross BlueShield of South Carolina is a leading health insurance provider that offers a variety of health plans, including individual and family plans, Medicare options, and group health plans. The organization focuses on providing coverage and resources for members, employers, and healthcare providers, ensuring access to quality healthcare services. With a commitment to promoting healthier lifestyles and supporting community health, BlueCross BlueShield of South Carolina plays a vital role in the healthcare landscape of the region.

📋 Description

• Perform medical surgical/pharmacy reviews using established criteria sets and/or utilization management within the LPN/LBSW scope of practice • Review professional, durable medical equipment, home health services, and pharmacy requests covered under the medical plan • Document decisions using indicated protocol sets or clinical guidelines • Provide support and review of medical claims and utilization practices • Perform authorization processes and ensure benefit coverage for appropriate medical/pharmacy services • Review interdepartmental requests and medical information to complete the utilization process • Determine eligibility, benefit levels, medical necessity, and reasonableness and necessity of services • Provide education to members and their families/caregivers • Conduct research to support thorough and accurate determinations • Support discharge planning by assisting and collaborating with Managed Care Coordinators • Educate internal and external customers on medical reviews, terminology, coverage determinations, coding procedures, and utilization management processes • Respond to members and providers with timely, accurate documentation of determinations • Maintain current knowledge of contracts and provider network status • Identify and refer cases to Medical Director, Subrogation, Quality of Care, Case Management, and other appropriate areas/staff

🎯 Requirements

• Bachelor's in a job-related field • Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing as degree equivalency • 2 years' working experience as LPN or LBSW • Working knowledge of word processing software • Good judgment skills • 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 • Proficiency with Microsoft Office • Active, unrestricted LPN/LVN licensure from the United States and in the state of hire, or active compact multistate unrestricted LPN license under the Nurse Licensure Compact, or active LBSW in the state of hire • Complete all required licenses and certificates and attend mandatory meetings • Ability to work independently, prioritize effectively, and make sound decisions • Preferred: 1 year of utilization review experience • Preferred: Knowledge of Microsoft Excel, Access, or other database software

🏖️ Benefits

• 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 • Opportunity to develop skills, advance careers and contribute abilities to company growth • Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs