LPN Utilization Management Coordinator

This is a fully remote position, open to applicants in South Carolina.

📋 Description

• Conduct medical surgical/pharmacy evaluations utilizing established criteria sets and/or within the LPN/LBSW scope of practice.

• Assess professional, durable medical equipment, home health services, and pharmacy requests that are covered by the medical plan.

• Document decisions following the specified protocol sets or clinical guidelines.

• Offer support and review medical claims and utilization practices.

• Execute authorization processes and confirm benefit coverage for relevant medical/pharmacy services.

• Analyze interdepartmental requests and medical information to finalize the utilization process.

• Assess eligibility, benefit levels, medical necessity, and the reasonableness and necessity of services.

• Provide education to members and their families/caregivers.

• Conduct research to ensure thorough and precise determinations.

• Assist and collaborate with Managed Care Coordinators to support discharge planning.

• Educate both internal and external customers regarding medical reviews, terminology, coverage determinations, coding procedures, and utilization management processes.

• Respond to members and providers promptly with accurate documentation of determinations.

• Maintain up-to-date knowledge of contracts and provider network status.

• Identify and refer cases to the Medical Director, Subrogation, Quality of Care, Case Management, and other relevant areas/staff.

⛳️ Requirements

• Bachelor's degree in a relevant field.

• Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing as degree equivalency.

• Minimum of 2 years' experience working as an LPN or LBSW.

• Proficient in word processing software.

• Strong judgment skills.

• Excellent customer service, organizational, and presentation abilities.

• Analytical or critical thinking capabilities.

• Ability to manage confidential or sensitive information discreetly.

• Competence in operating a computer with proficient typing skills.

• Strong oral and written communication abilities.

• Proficiency in Microsoft Office.

• Active, unrestricted LPN/LVN licensure from the United States and in the state of hire, or active compact multistate unrestricted LPN license under the Nurse Licensure Compact, or active LBSW in the state of hire.

• Fulfillment of all required licenses and certificates, along with attendance at mandatory meetings.

• Capability to work independently, prioritize tasks effectively, and make sound decisions.

• Preferred: 1 year of experience in utilization review.

• Preferred: Familiarity with Microsoft Excel, Access, or other database software.

🏝️ Benefits

• Subsidized health plans, including dental and vision coverage.

• 401k retirement savings plan with company matching contributions.

• Life Insurance coverage.

• Paid Time Off (PTO).

• On-site cafeterias and fitness centers at major locations.

• Education Assistance programs.

• Service Recognition initiatives.

• National discounts for movies, theaters, zoos, theme parks, and more.

• Opportunities for skill development, career advancement, and contributions to company growth.

• Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs.