Licensed Vocational Nurse

4 weeks ago

Rye, United States NavitsPartners Full time
Job DescriptionJob Description

Licensed Vocational Nurse (LVN)

Responsibilities:

  • Responsible for providing timely referral determination by accurate:
  • Usage of the Milliman Care Guidelines
  • Identification of referrals to the medical director for review
  • Appropriate letter language and coding (denials, deferrals, modifications)
  • Appropriate selection of the preferred and contracted providers
  • Proper identification of eligibility and health plan benefits
  • Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
  • Responsible for maintaining compliance in turnaround time requirements as mandated by the ICE TAT Standards
  • Responsible for working closely with manager to address issues and delays that can cause a failure to meet or maintain compliance.
  • Meets or exceeds production and quality metrics.
  • Work directly with the provider(s) and plan Medical Director to facilitate quality service to the member and provider.
  • Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management).
  • Attend all mandatory meetings and training.
  • Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
  • Collaborates, educates and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria.
  • All other job - related duties as it relates to the job function or as delegated by the management team.

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