- M i n i m u m 2 y e ars o f u tili z a tio n / care ma n ag e m e n t e x pe r ie n ce a ppl y i n g e v i d e n c e - b ased cr i t e r i a ( i . e . : M illi ma n , In te rq u a l ); CMS; H e a lt h pl an m edi cal p o li cy / c li n i cal c o v e rage g u id e li n e s required
- Ex pe r ie n ce p e r f o rm i n g m e di cal ma n ag e m e n t (UM) i n ele c t r o n i c r e f e rral ap pli c a t i o n p r e f e rr ed .
- Na v ig a tio n o f Sh are P oi n t o r eq u i v a le n t e x pe r i e n ce n a v ig a ti n g i n te r n al c o m p a n y i n t ra n e t p r e f e rr ed .
- 2 y e ars' w o rk e x pe r ie n ce in M i cr o s o f t W o rd, M i cr o s o f t Ex cel a n d M i cr o s o f t O u tlo ok p r e f e rr ed
- California Licensed Vocational Nurse required
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LVN Utilization Review - Fountain Valley, United States - MemorialCare Health System
Description
Title: LVN Utilization Review
Location: Fountain Valley
Department: Outpatient Utilization Management
Status: Per-diem
Shift: Days
Pay Range*: $40.00/hour
At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. Memorial Care stands for excellence in Healthcare.Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability.Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.
Position Summary
U n de r m i n i mal s u pe r v i s io n and using clinical experience, evidence-based knowledge and in collaboration with our physicians, to process clinically appropriate care management referrals.
Essential Functions and Responsibilities of the Job
1. A lo n g w it h p hy s i c i an h o sp i t a li s t s / P C Ps / S pe c i a li s t s, le ads a n d c oo rd i n a te s ac t iv itie s o f i n te rd i s c ip l i n ary t r e a t m e n t te am r eq u i r e d t o ma k e c o m ple x c l i n i ca l , be n e fi t a n d n et w o rk de c i s io n s.
2. An a l yz e d a t a t o ide n ti f y u nde r/ o v e r u ti l i z a t i o n ; i m p r ov e r e s o u rce c o n s u m ptio n ; p r o m o t e p o te nt i al r ed u c tio n i n c o s t ; a n d e n h a n ce q u a lit y o f care c o n s i s te n t w it h M e m o r i a l C are M e di cal F o un d a t i o n s t ra te g i c go a l s a n d ob j e c t iv e s.
3. A ppl y Utilization Review Ma n ag e m e n t p r o cess t o e n s u re c o n ti nu it y o f care t h r o u g h o u t t h e h e a lt h care c o n ti nuu m i n c l u di n g r e v ie w a n d a u t h o r i z a tio n o f services ap pl y i n g e v ide n c e - b a sed g u ide l i n e s a n d pe r M e m o r i a l C are M edi cal F o un d a tio n po l i c y .
4. A ss u r e s r e v ie w t u r n ar o un d ti m e s ad h e re t o t i m e li n e s s s t a n d ards set b y c o n t rac ti n g a n d r eg u l a to ry r eq u i r e m e n t s a n d e s t ab l i s h e d p r od u c ti vi t y a n d q u a lit y g u ideli n e s.
5. D e c i s i o n s a n d do c u m e n t a t i o n de m o n s t ra te p r u de n t u tili z a t io n o f r e s o u rces, id e n ti f ie s f o r pote nt i al c o st r ed u c t i o n ; p r o m o t e q u a lit y care a n d c o m pl y w it h r eg u l a to ry g u ide l i n e s n eede d t o ma i nt a i n deleg a te d s t a t u s f r o m c o n t rac te d h e a l t h pl a n s.
6. Assists with d e v el o ping c o rr e c t i v e ac t i o n pl a n s, crea t e po l i c ie s a n d de s ig n w o r kf lo w s t h at ope r a tio n a l i z e i m p r o v e m e n t s i de n ti fi e d t h r o u g h d a t a and leadership a n a l y s i s.
7. D o c u m e n t s de c i s i o n s t h at de m o n s t ra t e i n depe n d e n t j u dg m e n t , c r iti cal t h i nk i n g a n d ap pli ca t i o n o f c o m ple x ma n ag e d care r e g u l a t i o n s i n c l u di n g b u t n o t li m i t e d t o be n e f i t s t r u c t u r e s, health plan c o v e rag e , m edi cal n e cess i t y , n et w o rk c o n t rac t , f i n a n c i al r e sp o n s ib i lit y a n d care ma n ag e m e n t .
8. I m ple m e n t a n d ma i n t a i n s y s te ms a n d p r o cess e s t h at m ee t v ar io u s r eg u l a to ry r eq u i r e m e n t s.
9. In te rpr et s a n d ap plie s d e l e g a t i o n agr ee m e n t s, di v i s i on s o f f i n a n c i al r e sp o n s ibi l i ty , c o n t rac te d p r o v ide r l i s t s, e v ide n ce o f c o v e rag e , h e a lt h pl an ope r a tio n s ma nu a l s, a n d M e m o r i a l C are F o un d a tio n po l i c y .
10. In depe n de n tl y r e search a n d dete r m i n e t h e i nf o rma t io n n e cessary t o sa ti s f y sp e c i f i c b u s i n e ss a n d r eg u l a to ry m e d i cal ma n ag e m e n t r eq u i r e m e n t s. I nit i a te a n d c o m pl e t e t h e de n i al p r o c e ss f o r a l l services dee m e d t o b e n o n -c o v e r e d be n e f it s o r no t m edi ca l l y n e cessary.
11. May be called upon to par ti c ip a t e i n r eg u l a t o ry c o m pli a n ce a u di t r eq u i r e m e n t s a n d ac ti v itie s/c o mm i t tee s i n c l u di n g b u t n o t li m i te d t o U t ili z a t io n Ma n ag e m e n t , Q u a lit y I m p r o v e m e n t a n d Per f o rma n ce I m p r o v e m e n t .
12. Ma i n t a i n a n d de m o n s t ra t e a c o m ple t e un de rs t a n di n g o f o w n sc op e o f p rac ti ce o f li cens u r e and ed u ca tio n le v e l .
13. M o n ito rs u ti l i z a t i o n a n d p r o v ide s r e c o m m e n d a t i o n s f o r i m p r o v e m e n t aga i n st e s t ab li s h e d i n d u s t ry s t a n d ards a n d pe r f o rma n c e m e as u r e m e n t m et r i cs.
14. Works with Managers to o v e rsee ap p r o v a l , de n i al a n d ap pe al p r o cess, i n c l u d in g i m ple m e n t a t i o n o f ap p r op r i a t e de n i al l e t te r l a n g u age t o m e e t r eg u l a to ry s t a n d ards.
15. P a r ti c ip a te s i n C o n t rac ti n g a n d P r o v ide r Re l a t i o n s ac t iv itie s as n e cessary t o de v elo p a n d ma i n t a i n p r o vid er n et w o r k s.
16. Su b j e ct t o s t a n d ard m e d i c al ma n ag e m e n t pe r f o rma n ce meas u r e m e n t s f o r sp e c i f i c area/ te am i n c l u di n g b u t n o t li m i te d t o r e f e rral t u r n ar o un d ti m e s, v ol u m e , de n i al l a n g u age a n d o v e r t u rn ra te s.
17. May be required to travel during shift for meetings and staff oversite.
18. May be required to work remote to meet business needs for regulatory compliance.
*Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare—that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there's more... Check out our MemorialCare Benefits for more information about our Benefits and Rewards.
Qualifications
Experience
