Role Description As our Utilization Review LVN, your focus will be to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary. The LVN assists in determining appropriateness, quality and medical necessity of referral requests using pre-established guidelines. This position supports the Medical Group in effective management of the managed care patient. This position may be assigned cases in pre-authorization areas, in skilled nursing facility review or in concurrent review. To be successful in this role, you will effectively manage patient charts, demonstrating enthusiasm, efficiency, and empathy, while ensuring accurate application of criteria to support optimal patient care and operational flow.

• Manages assigned queues on a daily basis working oldest referrals first to assure 98% compliance with ICE timeframes.
• Follows job work aide in sequence of performing job, including checking eligibility on health plan websites. Demonstrates 100% accuracy of identification of Medical Group member before referral review is initiated.
• Determines correct type of referral and utilizes correct criteria in performing review and documents appropriate sections with 95% accuracy.
• Researches correct information and/or uses pend letter appropriately when facts are needed to reach determination.
• Preps case thoroughly, concisely and clearly for physician review. Researches EMR, criteria, medical policy and past history of member to detail case cleanly for MD. Watches for follow up and processes denials as indicated, demonstrating correct identification of reasons for denial.
• Recommends and coordinates interventions to facilitate high quality, cost-effective care, monitoring treatment, progress and outcomes of patients.

This position is work from home within California.

Qualifications

• 3 years Utilization Management (UM) experience.
• 5 years LVN experience.
• Clear and current CA Licensed Vocational Nurse (LVN) license.
• Strong knowledge nursing requirements in a clinical setting.
• Knowledge of utilization management programs as related to pre-set protocols and criteria.
• Knowledge of health plans, medical specialty procedures and diagnoses.
• Ability to work within an interdisciplinary structure and function independently in a fast paced environment while managing multiple priorities and meeting deadlines.
• Ability to apply clinical judgment to complex medical situations and make quick decisions.
• Ability to read and interpret benefit contract specifications.
• Ability to understand and follow established criteria and protocols used in managed care functions.
• Strong organization skills.
• Effective telephone and computer data entry skills.
• Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses.

Preferred Qualifications

• Experience at meeting deadlines by prioritizing work flow preferred.
• Physician group experience preferred.
• General knowledge of UM and Managed Care preferred.
• Use of InterQual guidelines preferred.
• Knowledge of California health plans and differences between commercial and advantage plans preferred.
• Familiarity with business practices and protocols with ability to access data and information using automated systems preferred.
• Ability to communicate effectively with coworkers, members, their families, physicians and health care providers preferred.