Licensed Vocational Nurse LVN/LPN PA Utilization Management Nurse Compact Lics
17 hours ago
As a member of the Optum Care Delivery team, you'll be an integral part of our vision to make healthcare better for everyone.
At Optum, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you'll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.
This position manages the pre-certification process for health care services requiring application of criteria and medical necessity prior to services being rendered for eligible members. The Utilization Management LVN acts as a liaison in evaluating incoming requests for medical services with communication to providers regarding specific information required for physician review, explanation of patient's benefits, and ensuring that medical care is not delayed by UM process. Timely and reliable preparation of cases for physician review is essential to ensure work flow results in accurate and consistent application of criteria.
If you have a compact license, you will have the flexibility to work remotely as you take on some tough challenges.
Primary Responsibilities:
- Monitors health care services in the determination of level of review required by service type as indicated by financial status or complexity
- Collects benefit, criteria and clinical information to perform clinical review decisions
- Gathers additional information and research requests for cases requiring presentation to medical director
- Generates referral entries accurately identifying the covered services authorized including ICD-9 coding, service groups and appropriate medical terminology in text
- Communicates to providers and patients regarding outcome of review
- Expedites requests that are required within 72 hours or have a high acuity of healthcare required
- Shows appropriate judgment in forwarding complex cases or new technology review to UM Medical director without delaying authorization request
- Verifies eligibility with accurate identification of patient benefit according to specific health plan enrollee
- Notifies patient and providers of referral determination in a professional manner with identification of critical needs that a patient may convey during notification
- Assists providers in referral processing related to urgent care required due to medical necessity of clinical data
- Partners with nurse reviewer coordinator to ensure timely faxing of referrals within mandated time frames with reliable documentation of notification
- Case preparation of intake form completed referrals in appropriate manner for auditing
- Serves as liaison between UM Department and Medical Groups and assist with benefit questions
- Collects and relays clinical information using approved medical terminology and acronyms
- Follows through with problem identification / resolution originated by supervisory staff regarding physician determinations
- Develops solid clinical skills in gathering information and entering into a case file for UR review
Quality
- Works independently without supervision in consistently meeting performance requirements of the UM program
- Communicates compliance information accurately to all parties
- Knowledge of resources that provide information on all managed care contracts, protocols, service groups, status and type codes
- Demonstrates consistent turn around times with pre-certification processing and notification
- Takes ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction and seek ways to improve job efficiency and makes suggestions to the appropriate manager
- Assures that member's care is maintained at an achievable level of quality in a cost efficient manner by using the WMMI provider network
- Ensures that pertinent information relating to the healthcare of patients is collected and readily available to the UM Committee for education and corrective action if indicated
- Attends educational offerings to keep abreast of change and comply with licensing requirements
Customer Service
- Performs all duties to customers in a prompt, pleasant, professional and responsible manner regardless of the stressful nature of the situation and always identifies self by name and title
- Maintains flexibility and enthusiasm and assist others when a staffing problem occurs including assisting other departments with phone coverage and word processing
- Respects customer and organizational confidentiality policy
- Works closely with medical director, providers and patients in the review of health care services with the development of decisions or actions to resolve problematic issues
- Preserves a positive working relationship and cooperates well with all departments
- Serves as liaison between UM Department, patients and providers
Compliance
- Demonstrates consistent turnaround time as stated in WMMI UM Program
- Coordinates quarterly audits with health plan in presenting data for review and intermediates with auditor on behalf of physician decisions
- Ensures compliance of the UM Program specifically with the Denial Process
- Forwards timely denial decisions to the denial area with a shared responsibility of notification to patient and provider for understanding of decision and benefit criteria
- Maintains basic knowledge of UM processes to ensure compliance and oversight of process of physician groups and Health Services Coordinators
- Keeps abreast of all new or revised WMMI policies and procedures when posted or distributed
- Attends educational offerings to keep abreast of change and comply with licensing requirements
Required Qualifications:
- High school diploma or GED
- Current LVN license in state of Texas
- Experience in physician office as clinical LVN
- Sound knowledge of managed care, medical terminology, referral process, and ICD-9 coding
- Proficient in PC software computer skills
Preferred Qualifications:
- 4+ years of clinical experience in primary care physician office or hospital setting
- 2+ years of experience in managed care or referral management position
- Prior Authorization experience
- InterQual or Milliman Knowledge / experience
- ICD-10, CPT coding knowledge / experience
- Utilization Review / Management experience
- Telephonic and/or telecommute experience
- Bilingual English/Spanish
- Proven ability to interact productively with individuals and with multidisciplinary teams
- Proven independent problem identification and resolution of patient issues originated by unfavorable decisions regarding medical care in support of physician reviewer decision by education of benefits and criteria standards
- Proven excellent verbal and written skills
- Proven planning, organizing, conflict resolution, negotiating, and essential interpersonal skills
All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors' offices. At WellMed our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we're making health care work better for everyone.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
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