Full-Time
Licensed Practical Nurse Utilization Management Coordinator 1
Posted on 9/9/2026
BlueCross BlueShield of South Carolina
Health insurance and plan administration
No salary listed
South Carolina, USA
Remote
Bachelor's
 Medical, Clinical & Veterinary |
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- A Bachelor's degree in a job-related field, or graduation from an accredited school of Licensed Practical Nursing or Licensed Vocational Nursing.
- Two years of work experience as an Licensed Practical Nurse or Licensed Bachelor of Social Work.
- 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.
- Working knowledge of Microsoft Office.
- Active, unrestricted Licensed Practical Nurse or Licensed Vocational Nurse licensure from the United States and the state of hire; an active compact multistate unrestricted Licensed Practical Nurse license under the Nurse Licensure Compact; or an active Licensed Bachelor of Social Work license in the state of hire.
- Completion of all required licenses and certificates and attendance at mandatory meetings.
- Perform medical, surgical, and pharmacy reviews using established criteria sets or clinical guidelines.
- Perform utilization management within the Licensed Practical Nurse or Licensed Bachelor of Social Work scope of practice for professional services, durable medical equipment, home health services, and pharmacy requests covered under the medical plan.
- Perform the authorization process and ensure benefit coverage for appropriate medical and pharmacy services based on established utilization management guidelines and criteria.
- Review interdepartmental requests and medical information to complete the utilization process.
- Review and determine eligibility, benefit levels, medical necessity, and the reasonableness and necessity of services.
- Provide education to members and their families or caregivers.
- Conduct research to establish a thorough and accurate basis for each determination.
- Support discharge planning by assisting and collaborating with Managed Care Coordinators as appropriate.
- Educate internal and external customers regarding medical reviews, medical terminology, coverage determinations, coding procedures, and utilization management processes in accordance with contractor guidelines.
- Respond accurately and promptly to members and providers regarding rendered determinations, with appropriate documentation.
- Maintain current knowledge of contracts and network status for all service providers and apply that knowledge appropriately.
- Identify and refer matters to appropriate areas or staff, including the Medical Director, Subrogation, Quality of Care, and Case Management.
- One year of utilization review experience.
- Ability to work independently, prioritize effectively, and make sound decisions.
- Persuasive, motivational, and influential abilities.
- Knowledge of Microsoft Excel, Microsoft Access, or other database software.
BlueCross BlueShield of South Carolina is a South Carolina-owned mutual health insurer and health-plan administrator. It offers individual, employer, Medicare and other coverage while operating provider networks, member services, claims and administrative programs. The organization also supports government and commercial health contracts through related businesses and specialized operations. This profile refers specifically to the South Carolina company, not the national Blue Cross Blue Shield Association, and centers on its role connecting members, employers, healthcare providers and public programs.
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