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    Licensed Vocational Nurse - Queens County, United States - NavitsPartners

    NavitsPartners
    NavitsPartners Queens County, United States

    3 weeks ago

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    Description

    Job Description

    Job Description

    Licensed Vocational Nurse (LVN)

    Responsibilities:

    • Responsible for providing timely referral determination by accurate:
    • Usage of the Milliman Care Guidelines
    • 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 maintaining compliance in turnaround time requirements as mandated by the ICE TAT Standards
    • Responsible for working closely with manager 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 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).
    • Attend all mandatory meetings and training.
    • Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
    • Collaborates, educates and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria.
    • All other job - related duties as it relates to the job function or as delegated by the management team.
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