LPN Utilization Management Coordinator I
New
B
BlueCross BlueShield of South CarolinaHealth insurance
Source API remote eligibility restrictions: United StatesFull-TimeJunior
Salary not disclosed
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Job Details
- Experience
- 2 years’ working experience as LPN or LBSW. Preferred: 1 year of utilization review experience.
- Required Skills
- Microsoft AccessMicrosoft ExcelMicrosoft Office
Requirements
- Have a bachelor’s degree in a job-related field, or be a graduate of an accredited school of Licensed Practical Nursing or Licensed Vocational Nursing.
- Have 2 years of working experience as an LPN or LBSW.
- Hold an active, unrestricted LPN/LVN license in the state of hire, an active compact multistate unrestricted LPN license under the Nurse Licensure Compact, or an active LBSW license in the state of hire.
- Have working knowledge of word processing software.
- Be proficient with Microsoft Office.
- Demonstrate good judgment, customer service, organizational, and presentation skills.
- Have analytical or critical-thinking skills and the ability to handle confidential or sensitive information discreetly.
- Be able to operate a computer and type proficiently.
- Have strong oral and written communication skills.
- Preferred: 1 year of utilization review experience.
- Preferred: knowledge of Microsoft Excel, Access, or other database software.
Responsibilities
- Perform medical, surgical, and pharmacy reviews using established criteria and clinical guidelines.
- Carry out authorization processes and assess benefit coverage for medical and pharmacy services.
- Review requests and medical information to determine eligibility, benefit levels, medical necessity, and service reasonableness.
- Document determinations using applicable protocols and guidelines.
- Research cases to establish a thorough and accurate basis for each determination.
- Provide education to members and their families or caregivers.
- Educate internal and external customers about medical reviews, terminology, coverage determinations, coding procedures, and utilization management processes.
- Respond to members and providers with timely, accurate determinations and documentation.
- Support discharge planning and collaborate with Managed Care Coordinators as appropriate.
- Refer cases to appropriate teams or staff, including Medical Director, Subrogation, Quality of Care, and Case Management.
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