LVN, Case Manager, Utilization Management - FT/Days (Finance)
Purpose Statement / Position Summary
Under supervision of Director of Medical Management provides utilization review and management for SHP members while at the same time coordinating quality of care, in a timely and cost-effective manner.
Consistently provides decision making, complies with turnaround time frames, follows UM criteria to ensure processing of request for referral authorizations will not interfere with or cause delay in service, or preclude delivery of services.
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.
Updates SHP systems to reflect current and ongoing authorization status
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.
Relays decision status of authorizations and pre-certs accurately to callers.
Interprets and applies appropriate, UM resources and information available on the Intranet, and in referral system to include but not limited to EOC's.
Faxes back to requested provider information needed if not received.
Communicates with the Enrollment Dept. when incorrect PCP member assignment
Gathers and assess relevant documentation to compare with MCG/UM Criteria.
Communicates with Utilization Physician Reviewer for follow-up and resolution of authorization referrals.
Verifies member insurance eligibility and benefits.
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
Experience
1-2 years acute care background preferred
1-year managed healthcare; health plan experience helpful
Prior experience in UM preferred.
Medical terminology proficient
Knowledge of ICD9-10
Knowledge of CPT codes
Education
Graduated from an accredited school of nursing
Must hold a current California unrestricted LVN license