[Hiring] Utilization Review LVN @CommonSpirit Health

Role Description

As our Utilization Review LVN, your focus will be to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary.

• Assist in determining appropriateness, quality and medical necessity of referral requests using pre-established guidelines.
• Support the Medical Group in effective management of the managed care patient.
• Manage patient charts, demonstrating enthusiasm, efficiency, and empathy.
• Ensure accurate application of criteria to support optimal patient care and operational flow.
• This position is work from home within California, with initial orientation onsite in the Sacramento region.
• Manage assigned queues on a daily basis working oldest referrals first to assure 98% compliance with ICE timeframes.
• Follow job work aide in sequence of performing job, including checking eligibility on health plan websites.
• Demonstrate 100% accuracy of identification of Medical Group member before referral review is initiated.
• Determine correct type of referral and utilize correct criteria in performing review and document appropriate sections with 95% accuracy.
• Research correct information and/or use pend letter appropriately when facts are needed to reach determination.
• Prep case thoroughly, concisely and clearly for physician review.
• Research EMR, criteria, medical policy and past history of member to detail case cleanly for MD.
• Watch for follow up and process denials as indicated, demonstrating correct identification of reasons for denial.
• Recommend and coordinate interventions to facilitate high quality, cost-effective care, monitoring treatment, progress and outcomes of patients.

Qualifications

• Three (3) years Utilization Management (UM) experience.
• Five (5) years LVN experience.
• Clear and current CA Licensed Vocational Nurse (LVN) license.
• Strong knowledge nursing requirements in a clinical setting.
• Knowledge of utilization management programs as related to pre-set protocols and criteria.
• Knowledge of health plans, medical specialty procedures and diagnoses.
• Ability to work within an interdisciplinary structure and function independently in a fast paced environment while managing multiple priorities and meeting deadlines.
• Ability to apply clinical judgment to complex medical situations and make quick decisions.
• Ability to read and interpret benefit contract specifications.
• Ability to understand and follow established criteria and protocols used in managed care functions.
• Strong organization skills.
• Effective telephone and computer data entry skills.
• Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses.

Requirements

• Experience at meeting deadlines by prioritizing work flow preferred.
• Physician group experience preferred.
• General knowledge of UM and Managed Care preferred.
• Use of InterQual guidelines preferred.
• Knowledge of California health plans and differences between commercial and advantage plans preferred.
• Familiarity with business practices and protocols with ability to access data and information using automated systems preferred.
• Ability to communicate effectively with coworkers, members, their families, physicians and health care providers preferred.