LPN Referral Specialist

3 days ago

Bethesda, Maryland, United States Ivyhill Technologies Full time
Job Summary

Ivyhill Technologies is seeking a skilled LPN Reviewer to join our team. As a key member of our referral management center, you will play a critical role in ensuring the smooth processing of referrals for our patients.

Key Responsibilities
  • Review referrals for administrative and clinical completeness, as well as Specialty Referral Guideline (SRG) compliance.
  • Complete the referral review process upon receipt of referral, ensuring timely and accurate processing.
  • Monitor and process referral management Genesis Work Lists (Genesis when applicable) to ensure consults are being processed within established guidelines.
  • Initiate, follow, manage, and close all referrals within timeline standards identified by the RMC business rules and other current Government policies, regulations, or memorandums.
  • Collaborate with appointing center, case managers, product line nurses, providers, clinics, manage care support contractor liaison, and other members of the healthcare team as needed.
  • Consult and collaborate with assigned product line nurse for clinical guidance as needed or instructed.
  • Coordinate and facilitate process for research and communicate with requesting providers, product line nurses, manage care support contractor, and others to ensure complete medical information is available to make informed decisions about a referral matter.
  • Verify patients' eligibility and ensure patients are registered in MHS-GENESIS.
  • Document in MHS-GENESIS, explains appropriate options to patients when they refuse appointments within access to care (i.e., point of service, Tricare Select, be connected to Beneficiary Counselor and Assistance Coordinator).
  • Interface with the MCSC and multidisciplinary personnel as needed to ensure appropriateness of referrals.
  • Submit referrals to non-network providers to TRICARE Service Center for medical necessity/appropriateness review.
  • Routinely monitor referral management voicemail to ensure patient calls are returned within the guidelines established.
  • Receive and appropriately forwards clinical concerns from patients to product line nurse or RM Leadership.
  • Advise patients of their referral status, including providing references for benefit counseling assistance and/or patient advocacy.
  • Provide information about EPRO to requestors outside the NCR requesting care within the NCR.
  • Assist Medicare beneficiaries in coordinating their medical care within the Direct Care System.
  • Close unused referrals as directed by DHA IPM, NCR MD policies and notifies ordering provider accordingly.
  • Understand the deferral process (when to defer for distance, capacity, capability, second opinion, command directed, continuity of care). Utilizes deferral codes appropriately.
  • Orients and trains new staff about the referral processes and timeliness.
Requirements
  • Qualified candidate must have a minimum of an associate degree and 2 years of experience, which demonstrates the ability to perform the duties of the position working in a MHS referral management center or clinic Medical Claims or as stated in number 1 below.
  • Will possess a Licensed Practical Nurse Certification/Licensure.
  • LPNs must have a current, active, full, and unrestricted License to practice nursing in accordance with State, and 2 years of clinical nursing experience is required.
  • Board requirements. License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency.
  • Must maintain license.
  • Possess excellent oral and written communication skills, interpersonal skills, superior customer service and organizational skills.
  • Have working knowledge of computers, specifically the Internet, Microsoft Word, Excel, PowerPoint, Access, and Windows.
Work Environment/Physical Requirements

The work can be sedentary. However, there may be some physical demands. Requirements include standing, sitting, or bending. Individual will be required to walk throughout the workplace and other military facilities.

Benefits

Ivyhill Technologies has a competitive benefits program which includes medical, dental and vision; Life and AD&D insurance; Short- and Long-Term Disability; supplemental Life insurance and a 401(k) Plan.

Ivyhill Technologies is an equal opportunity employer. In compliance with Federal and State Equal Opportunity Laws, qualified applicants are considered for all positions applied for without regard to race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, veteran status or any other legally protected status.

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