Utilization Review Nurse (LPN)
This position is responsible for performing discharge care coordination and review activities for determining efficiency, effectiveness and quality of medical/surgical services and serving as liaison between providers and Medical and Network Management Divisions. Review service requests, collect clinical and non-clinical data, verify eligibility, determine benefit levels in accordance to contract guidelines, conducting initial and concurrent review, prepare reports on quality of care, identify and report cases, and provide information regarding utilization management requirements and operational procedures to members, providers and facilities.
- Determine efficiency, effectiveness and quality of medical/surgical services, including appropriateness of hospital admissions, length of stay, level of care and discharge planning.
- Serve as liaison between providers and Medical and Network Management Divisions.
- Review service requests by receiving incoming calls, faxes, cases queued and return recorder messages to hospitals, providers and members.
- Determine contract eligibility and benefit coverage related to precertification and/or concurrent review requests based upon information provided by hospital personnel, members and providers.
- Determine contract eligibility and benefit coverage related to emergent referral requests.
- Collect clinical and non-clinical data and enter information into the medical management system.
- Utilize Medical Review Criteria, Medical Policy guidelines and internally developed review criteria to determine medical necessity, appropriateness of setting, including length of stay and type/duration of service.
- Identify provider contract status and provider network status including facility and physician contract status.
- Determine network status.
- Conduct research and obtain medical information to complete the referral/certification request.
- Utilize all Medical Management System applications to research and/or pend the precertification and referral authorization process.
- Pend/complete certifications and/or referral authorization requests according to established policies and procedures.
- Refer all requests that fail clinical review criteria to physician advisor.
- Provide verbal and written notification of referrals and preauthorization determinations according to established policies/procedures.
- Assess all cases for quality of care and report quality care issues when identified.
- Identify and refer cases for inclusion clinical programs.
- Report member and provider complaints according to established policies and procedures.
- Provide information regarding UM requirements and operational procedures to members, providers and facilities.
- Consult with supervisor/Medical Director regarding complex or difficult cases.
- Provide professional customer service at all times to internal and external customers.
- Follow facility procedures including checking in with designated facility personnel.
- Document referral and precertification information according to UM policies and procedures; include plan of care/treatment, patient condition and outcomes of care for appeals and cases failing clinical review criteria.
- Maintain knowledge of current regulatory agency standards (TDI, AAHCC/URAC, NCQA) and adhere to regulations and corporate procedures.
- Maintain knowledge of clinical and technological advances in medical/surgical care, including pharmacological therapy.
- Maintain knowledge of contract interpretation and containment measures (eligibility, extended care benefits and claims processing procedures).
- Must successfully complete the UM System Competency Verification Program and maintain competency with UM systems, regulatory agency standards, tele-servicing skills, documentation requirements, advancements in medical/surgical care including pharmacological therapy, CPT-4 and ICD-10 coding.
- Communicate and interact effectively and professionally with co-workers, management, customers, etc.
- Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
- Maintain complete confidentiality of company business.
- Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.