LVN Utilization Management

2 months ago

Blank, United States Allmed Staffing Inc Full time
Job DescriptionJob Description

Description:

What are the hours? ( Training hours?) M-F 8am-5pm PST
Will you be interviewing (face to face or phone) Phone (Video Conference)
Please confirm the worksite location - Telecommute, anywhere in the USA but must be licensed in California.
Are their additional health screenings required besides a drug and background check? (TB blood test, MMR, Varicella, Hep B titers, respirator medical clearance) No
Optum's Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.

General Role Description:
Under the general direction of the Director of UM, UM Manager, and the UM Supervisor, the Prior Authorization LVN ensures that prior authorization requests from patients and providers are completed in a timely fashion to meet the contractual and regulatory requirements while acting within the scope of their licensure. The Prior Authorization LVN will promote the quality and cost effectiveness of medical care provided to patients by applying clinical acumen and using appropriate nationally recognized guidelines, criteria, and evidence based standards. Also assists UM management and Compliance team in preparation for audits and other regulatory activities as needed.
Primary Responsibilities:

• 1 Acting within the scope of their license, ensures that prior authorization requests are appropriately reviewed and completed in a timely manner to meet contractual and regulatory requirements.
• 2 Coordinate and follow established prior authorization review process for outpatient and inpatient service requests.
• 3 Collaborates as directed with the Case Management Department or other departments as needed.
• 4 Accurate, thorough, and efficient review of prior authorization requests.
• 5 Timely review of prior authorization requests to include acute hospital pre-admission, surgical and diagnostic procedures, therapies, durable medical equipment, and home health care.
• 6 Conducts medical determinations based on nationally recognized and evidence based guidelines, and in accordance with the policies and procedures approved by the physician group Medical Directors and UM Committees.
• 7 Audits and evaluates patient medical records when determining benefit coverage and medical necessity, including appropriateness and level of care.
• 8 Reviews prior authorization requests in coordination with group Medical Directors as required.
• 9 Assists UM Coordinators and other clerical staff with issues and concerns that require clinical interpretation or definition including assisting patients with interpretation of criteria used in determinations as requested.
• 10 Assists in processing denial and extension letters using appropriate language, health literacy level, criteria, and policies.

Competency Requirements:

• 1 Strong clinical nursing background
• 2 Ability to work efficiently and effectively in multiple different utilization management software applications
• 3 Must be proficient in the application of Microsoft Word, Excel, Outlook, and the Internet.
• 4 Ability to multitask and work between multiple projects at one time.
• 5 Ability to effectively communicate verbally and in writing
• 6 Strong critical thinking skills
• 7 Knowledge of Medicare, DMHC, NCQA, and MCG Guidelines
• 8 Understanding of concepts and principles of managed care
• 9 Ability to evaluate and interpret medical records and other health care data and extrapolate critical information to make a sound clinical determination
• 10 Ability to use good judgement and tact when working with health care providers and beneficiaries
•
Preferred Qualifications:

Education/Training
Minimum: Graduate of an accredited school of nursing required.
Preferred: Bachelor's Degree in nursing or healthcare related field or current equivalent related work experience.
Experience
Minimum: One year clinical experience in an acute or ambulatory patient care setting including one year in a managed care environment such as a medical group, independent physician association, or health plan is required.
Preferred: One or more years experience in utilization management for a medical group or health plan.

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