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Utilization Mgmt Clinical LVN
4 months ago
Job Summary
We are searching for a Utilization Management Clinical LVN - someone who works well in a fast-paced setting. In this position, you will provide precertification of inpatient hospitalizations and outpatient procedures and services requiring authorization. This process includes clinical judgment, utilization management application, verification of benefits, denials, appeals, understanding of regulatory requirements, and medical necessity decisions utilizing nationally recognized criteria.
Responsibilities
* Assess the treatment plan, clinical information, and medical necessity of all requested services. Utilizes established criteria to appropriately certify requested services within the established timeframe required. Consults with providers regarding the patient's history and current care needs on an ongoing basis. Performs inpatient/outpatient preauthorization review and concurrent review as required by departmental needs. Provides/initiates discharge planning options within the network to providers and participates in coordinating the continuum of care.
* Facilitates provider communication and education. Notifies providers of approved services through written correspondence. Documents all activities and interactions in authorization systems. Promotes provider satisfaction with ongoing education regarding managed care and the process and procedure of the authorization requirements. Acts as liaison between providers and facilities to attain reasonable accessibility to promote quality of service and quality of care.
* Liaisons with payers and managed care staff members. Collaborates with all disciplines within the health plan to meet goals and objectives. Expeditiously communicates essential information between providers and HMOs to facilitate claims payment.
* Assess and refer potential case management cases. Screens and identifies potential members for referral to the TCHP case management department, meeting criteria for case management per the policy and procedure. Refers to potential members and collaborates with the case management team concerning medical history and current services being provided.
* Ongoing assessment for quality indicators and concerns. Identifies potential quality of care issues, tracks into an electronic system, and refers to appropriate QM staff. Works closely with UM Analyst to expedite appeals and complaint process by coordination of concurrent activity with policy and procedure requirements when applicable.
* Assess and process all denial determinations after the medical director review. Ensures the timeliness of all denial letters within regulatory requirements. Reviews all denial letters for appropriate regulatory verbiage, the accuracy of the individual contracted responsibility, and adherence to applicable policy and procedure about the denial letter process.
Qualifications
Be fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children's unless approved for a medical or religious exemption.
* Required H.S. Diploma or GED
* Required LVN - Lic-Licensed Vocational Nurses by the State of Texas
* Required 1-year managed care expertise and/or Utilization Management experience and 2 years' experience working as an LVN
Company Profile
Texas Children's Hospital
Since 1954, Texas Children's has been leading the charge in patient care, education, and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children's hospital in Texas, and among the top in the nation by U.S.News & World Report as well as recognition from Houston Business Journal as one of this city's Best Places to Work for ten consecutive years.
Texas Children's comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Center for pediatric research; Texas Children's Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children's Hospital West Campus, a community hospital in suburban West Houston; and Texas Children's Hospital The Woodlands, the first hospital devoted to children's care for communities north of Houston. We have also created the nation's first HMO for children, established the largest pediatric primary care network in the country and a global health program that is channeling care to children and women all over the world. Texas Children's Hospital is also academically affiliated with Baylor College of Medicine, one of the largest, most diverse, and successful pediatric programs in the nation.
To join our community of 14,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org. At Texas Children's Hospital, diversity, equity, and inclusion are at the core of our values and mission for all of our patients and families that we serve. We are committed to providing a diverse and inclusive work environment for all faculty, staff, and learners throughout our organization. We believe that each member of our one amazing team provides enrichment that allows us to create a lasting legacy for future employees of this great organization.
Texas Children's is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
