UM Coordinator II

Summary
 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.
Description
 

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.

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. 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.

To Qualify For This Position, You'll Need The Following:

• 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.

We Prefer That You Have The Following:

• 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.

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.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email [email protected] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information.

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