LVN- In Office

4 weeks ago

Dallas, United States Kris Anderson Consulting, LLC Full time

About the job LVN- In Office

This position is responsible for implementing and coordinating all utilization management functions relating to pre-certification of outpatient services. The LVN Case Manager in this capacity is responsible for coordinating authorizations and notifications.Provides workflow, direction, organization and monitoring of authorizations/utilization management. Coordinates and tracks authorization files between Authorization Coordinators and Physician reviewer.

Essential Functions and Responsibilities of the Job

  • Clear understanding of managed healthcare, utilization management
  • Possess knowledge of applicable regulatory standards and is able to prepare for audits based upon these standards
  • Ability to maintain compliance and turnaround time standards for all UM assignments
  • Provide excellent customer service to our members
  • Communicate effectively with a professional attitude.
  • Be responsible and accountable for all assignments and deliverables
  • Follow company policies, procedures and directives
  • Interact in a positive and constructive manner
  • Prioritize and multitask in a fast-paced work environment
Essential Job Outcomes
  • Inputs all information in referral system and ensures that all information is accurate.
  • Process referral authorization from providers in a timely manner, by utilizing established protocols.
  • Faxes back to requested provider information needed if not received.
  • Gathers and assess relevant documentation to compare with MCG/UM Criteria.
  • Communicates with Utilization Physician Reviewer for follow-up and resolution of authorization referrals.
  • Interacts effectively with providers, physician reviewers, and other departments using strong verbal and written communication skills on an on-going basis
  • Applies UM criteria appropriately to authorization requests
  • Apply Timeliness Standards to processing of referrals (ICE Timelines Grids)
  • Review and update authorizations as needed
  • Requests medical records or other information as needed to justify referrals
  • Other duties as assigned

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