SUMMARY

The purpose of the Utilization Management LVN is to ensure quality of patient care, effective utilization of available health services, review of admissions for medical necessity and necessity of continued stay in the inpatient setting. Ensures members have a safe discharge plan in place prior to discharge from the inpatient setting.

RESPONSIBILITIES AND DUTIES:

• Responsible for providing timely and accurate referral determination
• Identification of referrals to the medical director for review
• Appropriate letter language and coding (denials, deferrals, modifications)
• Appropriate selection of the preferred and contracted providers
• Proper identification of eligibility and health plan benefits
• Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
• Responsible for working closely with supervisor/lead to address issues and delays that can cause a failure to meet or maintain compliance.
• Meets or exceeds production and quality metrics.
• Work directly with the provider(s) and health plan Medical Director to facilitate quality service to the member and provider.
• Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management)..
• Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
• All other job related duties as assigned

EDUCATION & EXPERIENCE REQUIREMENTS:

• CA LVN license required.
• 3 to 5 years of acute care experience preferred.
• Two (2) years managed care experience in UM/CM Department, preferred

SKILLS & ABILITIES REQUIREMENTS:

• Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.
• ICD-9 and CPT coding experience a plus
• Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
• Experience in EZ-CAP preferred
• Medical Terminology preferred

PHYSICAL REQUIREMENTS:

• Body Positions: Sitting and standing for prolonged periods.

• Body Movements: Arm and hand dexterity.

• Body Senses: Must have command of close and distant sight, color perception and hearing.

• Strength: Ability to lift and move up to 25-pounds.

Working Environment:

• Work in an office, where the climate is controlled.
• OSHA exposure category: I

• Category I – Position includes tasks that involve exposure to Blood borne Pathogens.
• Category II – Position includes tasks that do not have exposure to Bloodborne Pathogens, however employment may require unplanned Category I tasks.
• Category III – Positions includes tasks that do not involve exposure to Bloodborne Pathogens. This position would not be required to perform Category I tasks.