(Archived) Utilization Management Licensed Practical Nurse

The Licensed Practical Nurse is responsible for assuring the receipt of high quality, cost efficient clinical outcomes for Persons Served (P/S) identified as having the need for certain inpatient and/or outpatient services determined to require precertification/preauthorization.

Review precertification requests for medical necessity, and work together with the medical provider for those request that require additional clinical information.Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians and exhibit strong team player abilitiesUse effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to: contribute to the promotion of improved quality of services, promote cost effective clinical outcomes, prevent re-hospitalization or more acute level of care, when possible and appropriate, and work collaboratively with the Aftercare Department to ensure proper continuity of care.Provide advice, counsel, and in-service on utilization management, as applicable.Identify appropriate alternative resources and demonstrate prudent decision-making and problem-solving abilities in managing each individual case. Maintain accurate records of all communications and provide timely verbal and written reports, as applicable.Prepare monthly reports to management, as applicable.May provide assistance with any needed preparation of quarterly performance and summary reports on P/S.Works to improve the utilization management process, including considerations of efficiency, effectiveness, and accuracy and support the Compliance, Quality, and PI initiatives of the organization.Identifies patients receiving the level of care requiring further justification for reimbursement purposes, through the review of the medical record and based on set reimbursement criteria protocols Identifies issues with referrals and providers in a timely manner, and coordinates the issue resolutions.Conducts a periodic review of the Utilization Management Process from the standpoints of efficiency, effectiveness, and accuracy and makes revisions, updates, and modifications as applicable and based on regulatory, policy, or operations changes. Utilizes highly proficient critical thinking skills in a day-to-day operation of the Utilization Department and applies standardized procedures to ensure consistency and compliance.Exhibits above-average decision-making abilities to effectively address unique situations. Must be able to apply principles of critical thinking to a variety of practical and emergent situations and accurately follow standardized procedures that may call for deviations.Must be able to apply sound judgment beyond a specific set of instructions and apply knowledge to different factual situations.Must be alert at all times; pay close attention to details.Must be able to work under stress on a regular or continuous basis.Perform other duties as assigned.

EOE Minorities/Females/Disabled/Vets.

Education:

• Graduation from an accredited college, university or vocational school.

Experience:

• Computer proficiency required. Experience in working with reimbursement agencies' negotiations, quality assurance personnel, case management, and clinical providers preferred. Familiarity with billing concepts, regulatory requirements, and basic coding principles desired.

Licenses/Certifications:

• Must hold current Licensed Practical Nurse license in the state of practice.