18615-Utilization Review Nurse (LPN)
Dallas, TX 75201 US
Utilization Review Nurse (LPN)
Location: Richardson, TX
Duration: 4 months
- Determine efficiency, effectiveness and quality of medical/surgical services, including appropriateness of hospital admissions, length of stay, level of care and discharge planning.
- Serve as liaison between providers and Medical and Network Management Divisions.
- Review service requests by receiving incoming calls, faxes, cases queued and return recorder messages to hospitals, providers and members.
- Determine contract eligibility and benefit coverage related to precertification and/or concurrent review requests based upon information provided by hospital personnel, members and providers.
- Determine contract eligibility and benefit coverage related to emergent referral requests.
- Collect clinical and non-clinical data and enter information into the medical management system.
- 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.
- Identify provider contract status and provider network status including facility and physician contract status.
- Determine network status.
- Conduct research and obtain medical information to complete the referral/certification request.
- Utilize all Medical Management System applications to research and/or pend the precertification and referral authorization process.
- Pend/complete certifications and/or referral authorization requests according to established policies and procedures.
- Refer all requests that fail clinical review criteria to physician advisor.
- Provide verbal and written notification of referrals and preauthorization determinations according to established policies/procedures.
- Assess all cases for quality of care and report quality care issues when identified.
- Identify and refer cases for inclusion clinical programs.
- Report member and provider complaints according to established policies and procedures.
- Provide information regarding UM requirements and operational procedures to members, providers and facilities.
- Consult with supervisor/Medical Director regarding complex or difficult cases.
- Provide professional customer service at all times to internal and external customers.
- Follow facility procedures including checking in with designated facility personnel.
- 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.
- Maintain knowledge of clinical and technological advances in medical/surgical care, including pharmacological therapy.
- Maintain knowledge of contract interpretation and containment measures (eligibility, extended care benefits and claims processing procedures).
- 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.
- Communicate and interact effectively and professionally with co-workers, management, customers, etc.
- Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
- Maintain complete confidentiality of company business.
- Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
- 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 . Incumbents with other clinical licenses are not required to obtain multi-state licenses.
- Utilization review or utilization management experience.
- MCG Certification.