United States only
Summary
We are currently hiring for a UM Coordinator I to join BlueCross BlueShield of South Carolina. In this role UM Coordinator I, you will perform 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, inpatient or outpatient services, durable medical equipment, home health services, and/or pharmacy requests covered under the medical plan. You will also document decisions using indicated protocol sets or clinical guidelines, provide support, and review of medical claims and utilization practices. Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!
Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.
Description
Logistics
This position is full time (40 hours/week) Monday-Friday and will be fully remote (W@H).
What You Will 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 Will Need:
Bachelors in a job-related field.
Graduate of Accredited School of Licensed Practical Nursing OR Licensed Vocational Nursing.
Two years working experience as LPN OR LBSW.
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.
Microsoft Office.
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.
What We Prefer:
Bachelor's degree – Nursing.
One year of utilization review experience.
Ability to work independently, prioritize effectively, and make sound decisions. Persuasive, motivational, and influential.
Knowledge of Microsoft Excel, Access, OR other database software.
WhatWe Can Do for You
401(k) retirement savings plan with company match.
Subsidized health plans and free vision coverage.
Life insurance.
Paid annual leave – the longer you work here, the more you earn.
Nine paid holidays.
On-site cafeterias and fitness centers in major locations.
Wellness programs and healthy lifestyle premium discount.
Tuition assistance.
Service recognition.
Incentive Plan.
Merit Plan.
Continuing education funds for additional certifications and certification renewal.
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 a recruiter to verify resume specifics and salary requirements.
Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
Some states have required notifications. Here'smore information.
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 minorities, females, disabled individuals and 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 physical and mental disabilities.
If you need special assistance or an accommodation while seeking employment, please e-mail [email protected] call 1-800-288-2227, 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.
