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LPN Utilization Management Coordinator
BlueCross BlueShield of South Carolina. Perform medical surgical/pharmacy reviews using established criteria sets .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical surgical and pharmacy reviews, utilization management, and benefit coverage determination. Proficient in documentation, communication, and education regarding medical claims and services.
Highest-signal resume keywords
Active LPN/LVN LicensureUtilization Review ExperienceMedical Claims ReviewEffective Communication SkillsAnalytical Thinking Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ManagementMedical Necessity DeterminationDocumentation ProtocolsBenefit Coverage AuthorizationConfidential Information Handling
Soft Skills
Good Judgment SkillsEffective Customer ServiceOrganizational SkillsPresentation SkillsAbility to Work Independently
Tools & Technologies
Microsoft OfficeMicrosoft ExcelMicrosoft AccessWord Processing Software
Certifications & Qualifications
Active LPN/LVN LicensureActive LBSW License
Industry Keywords
Medical Surgical ReviewsPharmacy ReviewsUtilization Management ProcessesDurable Medical EquipmentHome Health Services
About the role
Key responsibilities & impact- Perform medical surgical/pharmacy reviews using established criteria sets
- Perform utilization management within the LPN/LBSW scope of practice for professional, durable medical equipment, home health services, and pharmacy requests
- 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 regarding medical reviews, terminology, coverage determinations, coding procedures, and utilization management processes
- Respond to members and providers with accurate, timely documentation of determinations
- Maintain current knowledge of contracts and provider network status
- Complete required licenses and certificates and attend mandatory meetings
- Identify and refer cases to appropriate areas or staff, including Medical Director, Subrogation, Quality of Care, and Case Management
Requirements
What you’ll need- Required Education: Bachelors in a job-related field
- Degree Equivalency: Graduate of Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing
- 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
- 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 in state hired
- Ability to work independently, prioritize effectively, and make sound decisions (preferred)
- Persuasive, motivational, and influential (preferred)
- Knowledge of Microsoft Excel, Access, or other database software (preferred)
- 1 year of utilization review experience (preferred)
- Position is not eligible for sponsorship now or in the future
Benefits
Comp & perks- 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
- Diverse and inclusive workplace with opportunities to develop skills and advance careers
- Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs