LVN Utilization Manager
1 week ago
Job Summary:
Clinica Romero is seeking a highly skilled LVN Utilization Manager to join our team. As a key member of our clinical operations team, you will be responsible for ensuring that healthcare services are administered with quality, cost efficiency, and within compliance.
Key Responsibilities:
- Concurrent Review: Conduct concurrent reviews of patient clinical information to ensure efficiency and effectiveness of care.
- Precertification Requests: Review precertification requests for medical necessity and ensure that they meet established guidelines.
- Clinical Staff Monitoring: Monitor the activities of clinical and non-clinical staff to ensure that they are providing high-quality care and adhering to established protocols.
- Discharge Planning: Coordinate patient discharge planning needs with the healthcare team to ensure a smooth transition of care.
- Record Keeping: Maintain accurate records of all patient-related interactions and ensure that they are up-to-date and compliant with regulatory requirements.
- Reporting: Prepare monthly patient management and cost savings reports to provide insights into clinical operations and identify areas for improvement.
- Utilization Review: Perform utilization review activities, including precertification and retrospective reviews, according to established guidelines.
- Medical Necessity Determination: Determine the medical necessity of requests by performing first-level reviews using approved evidence-based guidelines and criteria.
- Telephone Calls: Answer Utilization Management directed telephone calls and manage them in a professional and competent manner.
- Case Referral: Refer cases to reviewing physicians when treatment requests do not meet necessity per guidelines or when guidelines are not available.
- Rate Negotiations: Conduct and document rate negotiations with out-of-network providers, utilizing appropriate reimbursement methodologies.
- Case Identification: Identify and refer potential cases to the appropriate department for follow-up.
- Quality Assurance: Consistently demonstrate excellence in quality assurance evaluations of work production.
- Teamwork: Take the initiative to work as a team with other medical staff to meet production goals.
- Process Improvement: Collaborate with leadership and management to identify areas for improvement in work processes.
- Supply Management: Monitor supplies and coordinate with the Office Manager to ensure the availability of adequate equipment and supplies required to provide patient care services.
- Therapeutic Patient Care: Provide therapeutic patient care within the scope of practice in accordance with the plan of care developed by the patient and provider.
- Patient Education: Enhance patient visits with providers by providing ongoing education to patients regarding treatments, disease processes, health maintenance, and medication adherence.
- Patient Group Education: Provide regularly scheduled patient group educational opportunities on various topics to be conducted in general meeting areas.
- Medication Administration: Give oral, intradermal, subcutaneous, intramuscular, topical medications, and treatments as ordered by providers.
- Walk-in Process: Facilitate the efficient flow of the walk-in process by monitoring patient conditions and identifying unexpected and/or significant findings as needed.
- Emergency Procedures: Initiate appropriate emergency procedures and communicate with providers/MD.
- Reporting Unusual Occurrences: Report to the MD any unusual occurrences in a timely fashion.
- Cleanliness and Equipment Maintenance: Ensure cleanliness of nursing areas, patient rooms, and proper functioning of equipment by visual inspection, routine testing, and other methods.
- Customer Service: Promote, ensure, and improve customer service to patients and staff by demonstrating skills consistent with the organization's values.
Qualifications/Requirements:
- License: Vocational Nurse
- Experience and Education: Minimum one year supervisory experience in a medical office, clinic, or other healthcare facility. High school graduate or GED equivalent; BA/BS or equivalent experience; completion of Board of Vocational Nursing.
- Cultural and Linguistic Competency: Cultural and linguistic competency and diversity sensitivity.
- Priority Management: Ability to manage priorities, workflow, and multiple tasks in an ever-changing environment.
- Versatility and Flexibility: Versatility, flexibility, willingness, and enthusiasm in a rapid pace environment.
- Attention to Detail: Attention to detail.
- Independence and Teamwork: Ability to work independently and as a member of various teams and committees.
- Interpersonal and Communication Skills: Strong interpersonal and communication skills.
- Policy Adherence: Ability to understand and adhere to established policies, procedures, and protocols.
- Charting and Documentation Skills: Strong charting/documentation skills.
- Bilingualism: Bilingual (English/Spanish) strongly recommended.
- CPR Certification: Must possess current CPR certification.
- Clerical and Administrative Skills: Strong clerical/administrative skills, including computer skills.
- Driver's License: Current California driver's license and legally required automobile insurance.
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