What are the responsibilities and job description for the LVN-Utilization Management Specialist - Case Management Social Services position at Eisenhower Medical Center?
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Linkedinchevron_left Back To ResultsLocated in the heart of the Coachella Valley, you have access to resort-style living and world-class amenities throughout Southern California.
Job Objective : A brief overview of the position.
The Utilization Review Nurse LVN will use skilled intervention and clinical best practice to concurrently screen admission review and review with payors in collaboration with Case Management for utilization issues. In addition, the UR LVN will disseminate information to improve service to patients / members, their families, and all staff members. Will do UR and enter data in EPIC.
Reports to
MANAGER, CASE MANAGEMENT
Supervises
N / A
Ages of Patients
Pediatric
Adolescent
Adult
Geriatric
Blood Borne Pathogens
Minimal / No Potential
Qualifications
Education
Preferred : Bachelor's degree in healthcare related field
Licensure / Certification
Required : Licensed Vocational Nurse in the State of California
Experience
Required : Three (3) years of LVN or Case Management experience
Essential Responsibilities
Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
Ensures appropriate authorization for commercial patients.
Serves as the first line responder to payor's clinical questions and for approval for admission, per established process. Manages the payor line appropriately.
Ensures appropriate demographic information has been communicated and pre-certification / verification obtained.
Contacts UR Nurse when requests for reviews come in.
Completes Medical Necessity reviews, documenting in electronic medical record according to established policies and procedures
Calls, faxes or electronically transmits reviews to payors.
Ensures authorization information is being communicated to the business office, per established processes.
Keeps attending physician updated and aware of authorization status. Notifies attending physician of any change in authorization status.
Follows up with payors to obtain authorization, after discharge
Enters all appropriate authorization issues for follow-up.
Tracks any outstanding authorization issues for follow-up.
Provides notification of discharges to insurance payors.
Notifies the UR Nurse and Denials Coordinator of potential denials.
Supports the denials coordinator to manage retrospective appeals and documents according to established policy.
Coordinates physician reviews with the UR Nurse, inpatient case manager and appropriate physicians for the denials management process.
Performs other duties as assigned.Apply Now
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LinkedinEisenhower Health offers a generous benefits package and a matched retirement plan.Employees are eligible to participate in a benefits program designed to make a difference for you and your family.View Full BenefitsA Culture of Positivity and SupportFrom the beginning, this organization formed a culture based on strong values, commitments and a passion for service and professional excellence.What Our Nurses SayOne of my very favorite things about working at Eisenhower Health is the culture on inclusivity that we have and a strong base for evidence-based practice.LoriNeonatal NurseOne of the greatest things about working as a nurse at Eisenhower Health is how much support you get from Administration. We keep on improving the process here. It's a fantastic place to work.RichardNursing SupervisorMy favorite thing about working at Eisenhower Health is the camaraderie within my unit and with the different departments.JenniferRegistered NurseBe a Part of an Award-Winning Team
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Rancho Mirage, CA
Full Time