Utilization Review LVN

About the role

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

• Review inpatient admissions for medical necessity and ensure safe discharge plans are in place
• Provide timely and accurate referral determination
• Identify referrals for medical director review
• Prepare appropriate letter language and coding (denials, deferrals, modifications)
• Select preferred and contracted providers appropriately
• Verify eligibility and health plan benefits
• Code to route records to the correct work queue or trigger proper determination notices
• Work closely with supervisor/lead to address issues and delays affecting compliance
• Meet or exceed production and quality metrics
• Collaborate with providers and health plan Medical Director to facilitate quality service
• Identify clinical program opportunities and refer members to appropriate healthcare programs (e.g., case management, engagement team, disease management)
• Maintain confidentiality of all business-related files, documents, and records
• Perform other job-related duties as assigned

Education & Experience Requirements

• CA LVN license required
• Minimum 3 years of acute care experience preferred
• Minimum two (2) years managed care experience in UM/CM Department preferred

Skills & Abilities

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

Physical requirements

• Positions: Sitting and standing for prolonged periods
• Movements: Arm and hand dexterity
• Senses: Close and distant sight, color perception and hearing
• Strength: Ability to lift and move up to 25 pounds

Working Environment

• Work in an office with controlled climate
• OSHA exposure category: I (Position includes tasks that involve exposure to Bloodborne Pathogens)

Pay

$39 - $56/hr

Schedule

Full Time, On Site