Utilization Review LPN, FT

Unity Health • Searcy, AR

5d

About The Position

The Utilization Review Licensed Practical Nurse (LPN) plays a critical role in ensuring that patients receive appropriate and efficient healthcare services. This position involves evaluating the necessity, appropriateness, and efficiency of healthcare services provided to patients, with the goal of optimizing patient outcomes while managing healthcare costs. The Utilization Review LPN collaborates closely with healthcare providers, insurance companies, and case managers to review medical records, assess treatment plans, and determine coverage eligibility. This role requires a thorough understanding of clinical guidelines, healthcare regulations, and insurance policies to make informed decisions regarding patient care. Ultimately, the Utilization Review LPN helps maintain high standards of care and supports the healthcare system's sustainability by promoting effective resource utilization.

Requirements

• Current and valid Licensed Practical Nurse (LPN) license in the United States.
• Minimum of 2 years clinical nursing experience, preferably in acute care or related healthcare settings.
• Basic understanding of medical terminology, clinical procedures, and healthcare documentation.
• Familiarity with healthcare insurance processes and utilization review principles.
• Strong communication and organizational skills.

Nice To Haves

• Experience in utilization review, case management, or healthcare quality assurance.
• Certification in Utilization Review or Case Management (e.g., Certified Professional in Utilization Review).
• Knowledge of healthcare regulations such as HIPAA and the Affordable Care Act.
• Proficiency with electronic medical records (EMR) systems and utilization review software.
• Additional nursing certifications or advanced training related to managed care or healthcare compliance.

Responsibilities

• Review patient medical records and treatment plans to assess the necessity and appropriateness of care.
• Collaborate with physicians, nurses, case managers, and insurance representatives to gather and verify clinical information.
• Evaluate healthcare services against established clinical guidelines and insurance policies to determine coverage eligibility.
• Document findings and communicate decisions regarding utilization review outcomes to relevant stakeholders.
• Participate in appeals and peer review processes when necessary to resolve coverage disputes.
• Maintain up-to-date knowledge of healthcare regulations, insurance requirements, and clinical best practices.
• Assist in identifying opportunities for improving patient care efficiency and reducing unnecessary healthcare expenditures.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed