Utilization Review Nurse (LPN)

Title:    Utilization Review Nurse (LPN)

Description:

BASIC FUNCTION:

This position is responsible for performing discharge care coordination and review activities for determining efficiency,effectiveness and quality of medical/surgical services and serving as liaison between providers and Medical and Network Management Divisions. Review service requests, collect clinical and non-clinical data, verify eligibility, determine benefit levels in accordance to contract guidelines, conducting initial and concurrent review, prepare reports on quality of care, identify and report cases, and provide information regarding utilization management requirements and operational procedures to members, providers and facilities.

ESSENTIAL FUNCTIONS:

1. Determine efficiency, effectiveness and quality of medical/surgical services, including appropriateness of hospital admissions, length of stay, level of care and discharge planning.
2. Serve as liaison between providers and Medical and Network Management Divisions.
3. Review service requests by receiving incoming calls, faxes, cases queued and return recorder messages to hospitals, providers and members.
4. Determine contract eligibility and benefit coverage related to precertification and/or concurrent review requests based upon information provided by hospital personnel, members and providers.
5. Determine contract eligibility and benefit coverage related to emergent referral requests.
6. Collect clinical and non-clinical data and enter information into the medical management system.
7. Utilize Medical Review Criteria, Medical Policy guidelines and internally developed review criteria to determine medical necessity, appropriateness of setting, including length of stay and type/duration of service.
8. Identify provider contract status and provider network status including facility and physician contract status.
9. Determine network status.
10. Conduct research and obtain medical information to complete the referral/certification request.
11. Utilize all Medical Management System applications to research and/or pend the precertification and referral authorization process.
12. Pend/complete certifications and/or referral authorization requests according to established policies and procedures.
13. Refer all requests that fail clinical review criteria to physician advisor.
14. Provide verbal and written notification of referrals and preauthorization determinations according to established policies/procedures.
15. Assess all cases for quality of care and report quality care issues when identified.
16. Identify and refer cases for inclusion clinical programs.
17. Report member and provider complaints according to established policies and procedures.
18. Provide information regarding UM requirements and operational procedures to members, providers and facilities.
19. Consult with supervisor/Medical Director regarding complex or difficult cases.
20. Provide professional customer service at all times to internal and external customers.
21. Follow facility procedures including checking in with designated facility personnel.
22. Document referral and precertification information according to UM policies and procedures; include plan of care/treatment, patient condition and outcomes of care for appeals and cases failing clinical review criteria.
23. Maintain knowledge of current regulatory agency standards (TDI, AAHCC/URAC, NCQA) and adhere to regulations and corporate procedures.
24. Maintain knowledge of clinical and technological advances in medical/surgical care, including pharmacological therapy.
25. Maintain knowledge of contract interpretation and containment measures (eligibility, extended care benefits and claims processing procedures).
26. Must successfully complete the UM System Competency Verification Program and maintain competency with UM systems, regulatory agency standards, tele-servicing skills, documentation requirements, advancements in medical/surgical care including pharmacological therapy, CPT-4 and ICD-10 coding.
27. Communicate and interact effectively and professionally with co-workers, management, customers, etc.
28. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
29. Maintain complete confidentiality of company business.
30. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS:

LVN with valid, current, unrestricted license in the state of operations.
3 years of clinical experience in physician office, hospital/surgical setting or health care insurance company.
Customer service oriented to assist internal/external customers.
Knowledge of medical terminology and procedures.
Verbal and written communication skills.
Interpersonal skills and team player.
Willingness and ability to travel.
Familiar with PC or database systems.
Incumbents with nursing licenses in positions/departments requiring multi-state licenses are required to obtain and maintain additional current, valid, and unrestricted applicable nursing licenses in other states as determined by management. Multi-state license fees will be provided by client. Incumbents with other clinical licenses are not required to obtain multi-state licenses.

PREFERRED JOB REQUIREMENTS:

Utilization review or utilization management experience.
MCG Certification.
 

Mandatory skills:

Utilization management,
Network Management, provider contract status, provider network status, physician contract status, network status, CPT-4, ICD-10 coding,
TDI, AAHCC, URAC, NCQA,
care benefits, claims processing procedure, care coordination, pharmacological therapy, managed care , Holistic Health Management,
UM System Competency Verification Program, UM systems, UM requirements, UM policies, UM procedure,
customer service,
surgical services, clinical data, clinical review, clinical, health care, surgical care,
plan of care, treatment, patient condition, regulatory agency standards, tele servicing,
medical terminology, medical procedure, medical management system, medical, medical necessity, Medical Review Criteria, Medical Policy guidelines, medical services

VIVA USA is an equal opportunity employer and is committed to maintaining a professional working environment that is free from discrimination and unlawful harassment. The Management, contractors, and staff of VIVA USA shall respect others without regard to race, sex, religion, age, color, creed, national or ethnic origin, physical, mental or sensory disability, marital status, sexual orientation, or status as a Vietnam-era, recently separated veteran, Active war time or campaign badge veteran, Armed forces service medal veteran, or disabled veteran.