Utilization Review LPN

Carroll County Memorial Hospital•Carrollton, KY

4d•Onsite

About The Position

Carroll County Memorial Hospital’s role is to improve the health and well-being of the residents and visitors to Carroll County and surrounding counties, by providing quality, compassionate, cost effective and convenient health care through community leadership and in collaboration with other healthcare organizations which serve our communities. The Utilization Review Licensed Practical Nurse (LPN) is to support the hospital's utilization management program by assisting with the review and monitoring of patient care services to ensure appropriate utilization of healthcare resources, compliance with regulatory and payer requirements, and accurate clinical documentation. The Utilization Review LPN collaborates with providers, nursing staff, case management, and payers to facilitate timely authorizations, support medical necessity determinations, and promote efficient, high-quality patient care while helping to optimize reimbursement and organizational performance.

Requirements

Kentucky Licensed Practical Nurse required
Minimum of two years direct clinical experience required
Data analysis and interpretation skills.
Strong organizational and prioritization skills needed
Dependable, self-directed and pleasant.
Adaptable and flexible to meet patient/family and department/facility needs

Nice To Haves

CCM preferred
Minimum of two years experience in Utilization, Quality, or Case Management preferred
Knowledge of acute care regulatory/accreditation requirements, discharge planning and Quality Improvement experience preferred

Responsibilities

Ensures cost effective patient care services.
Provides specific recommendations to care team members regarding cost-effective alternatives
Assess admission criteria and length of stay, applying standardized clinical guidelines such as MCG to justify care levels
Issues pre-authorizations for procedures, medications, and durable medical equipment by providing clinical information to insurance carriers
Collaborate with physicians and other healthcare providers to discuss patient care plans and ensure alignment with coverage policies
Identify and refer cases to case management or social work for complex discharge planning needs
Facilitate communication between medical staff and payers to resolve issues related to treatment plans and reimbursement
Prepare and submit clinical appeals to insurance companies when services are denied, providing documentation to support medical necessity
Advocate on behalf of patients to identify, address, and intervene on physical and psychosocial health care needs
Analyze care needs of patients and monitors progress toward desired outcome goals and tracks and analyzes clinical and financial data to support clinical decision-making
Upon admission, develop an initial individualized Case Management plan through assessment data, identification of resources, and post-acute options beginning with admission
Communicate and collaborate with patient/family/ significant other, and all members of the care team throughout the continuum.
Begin appropriate referrals as indicated, i.e., Social Services, Physician Advisor, and Medical Director
Monitor and evaluate daily patient’s progress via chart review to ensure cost/benefit value, continuity of care, Case Management Plan modification, patient/family satisfaction and compliance.
Intervene immediately with Team Leader or appropriate team members if clinical or system variances are identified that delay progress through the course of care
Collects appropriate data and completes tracking/trending logs in a timely manner
Communicates abnormal lab results, questionable health history and physical findings to the appropriate Nursing personnel