Utilization Review Nurse (LPN)

1199seiu•New York, NY

10d

About The Position

Responsibilities • Process prospective, concurrent, retrospective Utilization Management (UM) medical requests • Ensure compliance with Utilization Management determinations, retro reviews, and case management programs according to SPD, time frames, clinical policies, and operational workflows • Maintain, monitor, and review the UM workflow to ensure coverage determinations are processed efficiently, timely, accurately, and consistently • Work within Document Management System (DMS) and follow workflows for assigned concurrent, retrospective UM medical requests • Identifying gaps of care, need for specialized services and equipment outlining action plan with applicable disciplines and vendors • Authorize vendor services based on skilled need and or medical necessity applying relevant • Departmental Policy and Procedures, Reference Guides, Checklists and Milliman Care Guidelines • Troubleshoot and intervene with difficult vendors/providers and assist with urgent/expedited/complex cases that require management level problem solution. • Work closely with medical advisors and management team for escalated complex UM requests • Conduct internet research to retrieve data for complex cases • Serve as a liaison with other departments and ensure effective communication with all areas of the Fund • Establishes proactive approach to problem solving • Comply with UM productivity standards, track, and report regularly • Maintain appropriate documentation of all services in keeping with all confidentiality and HIPPA regulations • Perform special projects and assignments as directed by management Qualifications • Associate's degree and Valid Licensed Practical Nurse (LPN) required • Minimum three (3) years working in a clinical setting, such i.e., inpatient hospital and pertinent outpatient services (i.e., homecare vendors) experience plus minimum two (2) years of Utilization Management experience required. • BSN and Certification in Case Management a plus • Working experience utilizing Milliman Care Guidelines • Strong clinical skills and background. • Intermediate level Microsoft Word, Excel, and Outlook. • Internet research for investigating and retrieving pertinent data for complex inquiries. • Effective time management skills. • Must have the ability to exercise judgment and discretion in establishing and maintaining good work habits and relationships, maintaining the confidentiality of the position in all dealings • Ability to work in fast-paced high volume work environment, maintain professional manner and presentation, multi-task, establish priorities, delegate, meet deadlines and follow through on assignments

Requirements

Associate's degree and Valid Licensed Practical Nurse (LPN) required
Minimum three (3) years working in a clinical setting, such i.e., inpatient hospital and pertinent outpatient services (i.e., homecare vendors) experience plus minimum two (2) years of Utilization Management experience required.
Strong clinical skills and background.
Intermediate level Microsoft Word, Excel, and Outlook.
Internet research for investigating and retrieving pertinent data for complex inquiries.
Effective time management skills.
Must have the ability to exercise judgment and discretion in establishing and maintaining good work habits and relationships, maintaining the confidentiality of the position in all dealings
Ability to work in fast-paced high volume work environment, maintain professional manner and presentation, multi-task, establish priorities, delegate, meet deadlines and follow through on assignments

Nice To Haves

BSN and Certification in Case Management a plus
Working experience utilizing Milliman Care Guidelines

Responsibilities

Process prospective, concurrent, retrospective Utilization Management (UM) medical requests
Ensure compliance with Utilization Management determinations, retro reviews, and case management programs according to SPD, time frames, clinical policies, and operational workflows
Maintain, monitor, and review the UM workflow to ensure coverage determinations are processed efficiently, timely, accurately, and consistently
Work within Document Management System (DMS) and follow workflows for assigned concurrent, retrospective UM medical requests
Identifying gaps of care, need for specialized services and equipment outlining action plan with applicable disciplines and vendors
Authorize vendor services based on skilled need and or medical necessity applying relevant Departmental Policy and Procedures, Reference Guides, Checklists and Milliman Care Guidelines
Troubleshoot and intervene with difficult vendors/providers and assist with urgent/expedited/complex cases that require management level problem solution.
Work closely with medical advisors and management team for escalated complex UM requests
Conduct internet research to retrieve data for complex cases
Serve as a liaison with other departments and ensure effective communication with all areas of the Fund
Establishes proactive approach to problem solving
Comply with UM productivity standards, track, and report regularly
Maintain appropriate documentation of all services in keeping with all confidentiality and HIPPA regulations
Perform special projects and assignments as directed by management