Utilization Reviewer - LPN
Summary
| Title: | Utilization Reviewer - LPN |
|---|---|
| ID: | UM17 |
| Location: | Rochester |
| Job Type: | Temporary (Full-time) |
| Date Posted: | 08/16/2018 |
| Openings: | 1 |
| Department: | Utilization Management |
Description
GRADE: 207
POSITION SUMMARY
Provides utilization review, including review of referrals, prior authorization and claims adjudication.
ESSENTIAL JOB DUTIES/FUNCTIONS
OTHER FUNCTIONS AND RESPONSIBILITIES
- Participate in new Monroe Plan staff orientation.
- Assist other members of the Clinical Services team as needed.
- Performs other duties as assigned.
MINIMUM REQUIREMENTS/LICENSES/CERTIFICATIONS
- A minimum of two years experience in general medicine/surgery/home care preferred.
- Prior UR experiences a plus.
POSITION SUMMARY
Provides utilization review, including review of referrals, prior authorization and claims adjudication.
ESSENTIAL JOB DUTIES/FUNCTIONS
|
% of Time
|
Essential Function |
75 |
Principal Accountabilities - Under the supervision of a Registered Nurse, performs initial utilization review activities including prospective, concurrent and retrospective reviews. Initial utilization review involves reviewing and approving the medical necessity of proposed or previously provided services, and referring cases that may not meet the Monroe Plan's clinical guidelines to a Medical Director for further consideration. In accordance with applicable law, all medical necessity denials must be made by a Medical Director.
- Ensures time frames are met on all activity (e.g.: clinical reviews.) - Maintains Inter-rater reliability on all service requests. - Reviews treatment plans with providers and or facilities to assess treatment progress and medically necessary care, according to prescribed protocols.
- Maintains current and accurate records for all service requests. - Assists RN to ensure NCQA, HEDIS and DOH requirements relative to patient care are met or exceeded across all lines of business. - Gathers information for BCBS consumer advocate department to respond to fair hearing requests, and returns to BCBS in a timely manner.
- Maintains all confidentiality policies and procedures according to HIPAA regulations. - In conjunction with the manager, identify and develop clinically appropriate cost effective programs to improve quality of care for members receiving clinical services through Monroe Plan. - Assure improved health care outcomes by identifying and referring to case management department, members who may benefit from case management services. Assists Informatics Department in development and support of informatics systems: QWS, EPACES, PHI website and Control D.] |
|
25 |
Claims clinical review - Assist provider relations staff with fee schedule issues.
- Review clinical pended claims for appropriateness of services. |
OTHER FUNCTIONS AND RESPONSIBILITIES
- Participate in new Monroe Plan staff orientation.
- Assist other members of the Clinical Services team as needed.
- Performs other duties as assigned.
- Must possess a current NYS LPN licensure.
- Ability to demonstrate excellent communication skills both oral and written, as well as, strong interpersonal skills.
- Ability to work independently and have an understanding of utilization management, treatment planning and discharge planning.
- Strong organizational skills.
- Excellent typing and computer skills required.
- Strong organizational skills.
PREFERRED QUALIFICATIONS
- Ability to demonstrate excellent communication skills both oral and written, as well as, strong interpersonal skills.
- Ability to work independently and have an understanding of utilization management, treatment planning and discharge planning.
- Strong organizational skills.
- Excellent typing and computer skills required.
- Strong organizational skills.
- A minimum of two years experience in general medicine/surgery/home care preferred.
- Prior UR experiences a plus.
This opening is closed and is no longer accepting applications
