Utilization Review LVN

3 weeks ago

Bakersfield, United States Common Spirit Full time

Overview

* This position is remote with a clear and current CA LVN license.

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health's Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups hospitals health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options including medical dental and vision plans for the employee and their dependents Health Spending Account (HSA) Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

Responsibilities

* This position is remote with a clear and current CA LVN license.

Position Summary:

The Utilization Review LVN uses clinical judgement in providing utilization management services. The focus is to provide high quality cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary.

Responsibilities may include:

* Conducts pre-authorization referral reviews following workflow as written document criteria to make determination or recommendation and process the referral in a timely manner.
* Researches correct information and/or uses pend letter appropriately when facts are needed to reach determination.
* Preps case thoroughly concisely and clearly for physician review. Researches EMR criteria medical policy and past history of member to detail case cleanly for MD.
* Watches for follow up and processes denials as indicated.
* Performs audits of medical records as requested or appropriate.
* Recommends and coordinates interventions to facilitate high quality cost-effective care monitoring treatment progress and outcomes of patients.
* Performs other duties as assigned.

Qualifications

Minimum Qualifications:

* Minimum 3-5 years of healthcare experience with general knowledge of Utilization Management and Managed Care.
* Graduate of accredited school of nursing; Clear and current CA Licensed Vocational Nurse (LVN) license.
* Must be able to communicate clearly and concisely with all levels of individuals sometimes in stressful situations. Demonstrated ability to independently evaluate and interpret clinical information and care planning. Ability to perform job functions independently and with minimal supervision.
* Effective oral written and listening communication skills necessary for constant interaction with patients families physicians and other members of the health team.
* Able to stay organized and flexible in a work environment with multiple assignments and changing priorities
* Word processing keyboarding and non-scripted documentation skills. Able to operate PC-based software program.

Preferred Qualifications:

* Preferred 5-7 years of experience in combination of utilization management prior authorization or acute/sub-acute care experience.
* Understanding of assessment tools such as InterQual MCG and DRGs preferred.
* Direct experience working with Managed Care and Medicare/Medicaid Regulations preferred.
* Direct experience working with physicians preferred.

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