UM Coordiator 1

Summary
 As a 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, 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. You will also provide support and review of medical claims and utilization practices.
Description
 

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 have 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 committed to the same philosophy, consider joining our team!

Logistics: BlueCross BlueShield of South Carolina

Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. It may be necessary, given the business need to work occasional overtime. Employee may have option to work from home but will involve occasional required in-house meetings / training. Onsite work will be located at 4101 Percival Rd. Columbia, SC, 29229. You may be required to travel between buildings.

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.
• Utilize allocated resources to back up review determination.
• Review interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
• Review/determine eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
• Provide education to members and their families/caregivers.
• Conduct research necessary to make thorough/accurate basis for each determination made.
• Support the discharge planning process by assisting and collaborating with Managed Care Coordinators as appropriate.
• Educate internal/external customers regarding medical reviews, medical terminology, coverage determinations, coding procedures, and UM processes, etc. in accordance with contractor guidelines.
• Respond accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• Maintain current knowledge of contracts and network status of all service providers and applies appropriately.
• Complete all Required Licenses and Certificates and attends mandatory meetings.
• Identify 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: Bachelor's Degree in a job-related field.
• Degree Equivalency: Graduate of Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing. 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.
• Required Work Experience: Two 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.
   

We Prefer That You Have the Following:

• Preferred Education: Associate degree in nursing.
• Preferred Work Experience: 1 year of utilization review experience.
• Preferred Skills and Abilities: Ability to work independently, prioritize effectively, and make sound decisions. Persuasive, motivational, and influential.
• Preferred Software and Tools: Knowledge of Microsoft Excel, Access, or other database software.

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.

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 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.

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's more 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] or 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.