Utilization Management Coordinator I

For more than six decades, BlueCross BlueShield of South Carolina has been part of the national landscape. Our roots are firmly embedded in the state. We are the largest insurance company in South Carolina. We are also the only one that has an A+ Superior A.M. Best rating. We are one of the nation's leading government contract administrators. We operate one of the most sophisticated data processing centers in the Southeast and have a diverse family of subsidiary companies. Our full-time employees enjoy benefits like a 401(k) retirement savings plan with company match, subsidized health plans, free vision coverage, life insurance, paid annual leave and holidays, wellness programs and education assistance. If you are a full-time employee in the National Guard or reserves, we will cover the difference in your pay if you are called to active duty. BlueCross has a dedicated corporate culture of community support. Our employees are some of the most giving in the country. They support dozens of nonprofit organizations every year. If you're ready to join a diverse company with secure, community roots and an innovative future, apply for a position now! BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

We are currently hiring for a Utilization Management Coordinator I to join BlueCross BlueShield of South Carolina. In this role as a Utilization Management Coordinator I, you will perform medical/pharmacy reviews using established criteria sets and/or perform 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 and provide support and review of medical claims and utilization practices. Location: This position is full-time (40 hours/week) Monday-Friday from 8:30am – 5:00pm and will be fully remote. The candidate will be required to report on-site for the first 3 days of the job and may be required to come on-site for occasional trainings, meetings, or other business needs.

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.).