Location: Rancho Mirage,CA, USA
R0271233
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.
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