Utilization Management /LPN Care Manager (Level 1)
|Title:||Utilization Management /LPN Care Manager (Level 1)|
Utilization Management Nurse/Care Manager LPN (Level 1)
Perform pre-certification, certification and/or authorization activities for all requested Home Health Services included as contracted services that meet eligibility and benefits coverage. Responsible for certification determinations and sending written authorizations to referring physician and home health care provider. When necessary, requests additional clinical information from member’s care providers. Refers requests that do not meet coverage guidelines criteria to RN Case Manager for a Level II Review.
- Identifies themselves by name, title and company name on all telephone calls.
- Provides upon request information on specific UM requirements and procedures.
- Research beneficiary history prior to determination escalating those that do not meet guidelines to second level review nurse per department procedures.
- Answers the telephone and provider and member requests in a timely and polite manner.
- Is responsible for authorizations to be completed within specified time frames in department policy. Proactively escalating those cases that are at risk of not being completed within department policy.
- Adheres to clinical review scripts, criteria and department protocols in all case authorizations.
- Distributes appropriate authorization letters to providers and members in compliance with department policies and time frames.
- Notifies referral source if request for service is a non-covered benefit by telephone or fax.
- Requests additional information via telephone for referrals that are incomplete and documents request in the member record.
- Consults with RN or CMO if there are questions regarding the case meeting clinical criteria.
- Refers authorized requests to the staffing team to research and secure a home health care provider for the requested and authorized services, in order for the case to be staffed within one business day.
- Documents all member and provider complaints in the appropriate data base and escalates complaints to RN or department supervisor for further action and resolution.
- Maintains and respects confidentiality of member/physician/personnel information
- Responsible for accurate review and entry of authorization data into computerized database. Enters clinical documentation, authorization numbers and tracking numbers.
- Answers incoming telephone and fax authorization questions regarding status.
- Performs all aspects of member care in an environment that optimizes member safety and reduces the likelihood of medical/health care errors.
- Knowledgeable of current Medicare and Medicaid requirements, necessity and justification requirements.
- Maintains a good rapport with physicians, private insurance companies and government agencies.
- Maintains a good working relationship both within the department and with other departments.
- Consults other departments as appropriate to collaborate in member care and performance improvement activities.
- Participates in performance improvement activities for department and CQI activities.
- Accepts additional assignments willingly.
Licensed Practical Nurse; minimum of 5 years of experience in a variety of health care settings
Home health experience preferred
Current state license in the state where membership lives.
Ability to read and communicate effectively in English.
Additional languages preferred.
Basic computer knowledge such as Word and Excel.
Excellent customer service and follow-up skills
Ability to sit for long periods and read monitors.
Strong attention to detail
For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.
Job Type: Full-time
- Utilization Management/Home Health Care: 5 years
- High school or equivalent
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