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LPN,Utilization Management

Company: Optum
Location: Tacoma
Posted on: September 15, 2020

Job Description:

Job_Description Utilization Management Nurse Department: Clinical Operations Status: Regular Full-Time, FLSA Non-exempt Location: In and around Pierce County, WA Reports to: Utilization Management Manager Job_Summary The Utilization Management Nurse will conduct reviews of requested healthcare services and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination in accordance with Utilization Management policies and procedures. This position collaborates with patients, families and stakeholders to provide the level of care necessary to meet the patients needs. The UM Nurse provides planning and care coordination to facilitate transition plans to the appropriate level of care across the care continuum. Essential_Duties_&_Responsibilities * Communicates directly with providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services * Performs utilization and concurrent reviews of all inpatient stays using InterQual/Milliman criteria, approves bed days, identifies and evaluates delays in care, initiates discharge planning, arranges alternative care settings when medically appropriate * Manages and follows relevant time frame standards for conducting and communicating utilization review determinations * Works closely with relevant medical entities to assure patients are transitioned to appropriate levels of care and all supporting resources are available either through the healthcare benefits or other supporting entity * Prepares for oversight audits by the health plans and responds to appeal requests * Monitors and evaluates medical services and community based resources to meet the individual patient s health needs at time of care transition * Follow up with ancillary contracted entities if services or resources have not been made available to the patient to assure that medical needs are being met * Makes appropriate care management referrals through triage process during care transition to case management staff * Reviews written requests for clinical services for medical appropriateness * Interfaces with referring practitioners or staff, to facilitate care alternatives within specified time restrictions * Facilitates understanding in the areas of case management, quality management, utilization management, patient education and preventive health guidelines to promote health plan expectations and refers patients for appropriate services * Responds to questions from medical offices, hospitals, and patients about the necessary steps of the medical referral authorization process * Manages utilization review authorizations, both verbal and written to assure high continuity of care for all managed care patients in the program and consistency of gathering specific information within the department to comply with policies and procedures. * Review and respond to all reconsideration and appeal requests within timeframes outlined by the health plan. * Work closely with patient s family and social services to ensure prop information is disseminated to all stakeholders * Works closely with the CMO to obtain timely medical decisions on pended referrals and requests for medical services from health plans and providers * Notifies CEO, CMO, Clinical, Claims and Practice Support Directors of any costly medical cases that will reach stop-loss levels * Submit TPL notifications of any potential Workers Comp. or Third Party Liability cases that NPN may not be financially responsible for to the appropriate departments KNOWLEDGE, SKILLS AND ABILITIES * Knowledge of advanced clinical standards, practices, and procedures for designated patient population * Knowledge of Medicare, Medicaid and commercial payor guidelines * Demonstrates expertise in the application of InterQual/Milliman criteria * Knowledge and understanding of NCQA Guidelines * Knowledge of, and skill in, the use of personal computer and Microsoft Office Suite * Knowledge of age specific communication needs with the ability to listen actively and respond to internal and external customers in a timely, competent manner both verbally and nonverbally * Skill in teaching and nursing process * Ability to make presentations in a public setting * Ability to maintain confidentiality of patient and all related entity business matters of the organization and its partners * Ability to maintain professional demeanor in resolving conflicts * Ability to work cohesively with team, patients, physicians and medical staff to articulate complex concepts in managed care and coordinated care principles * The ability to interpret financial cost analysis reports MINIMUM QUALIFICATIONS Education: Licensed Practical Nurse certification or Associates Degree in Nursing Experience * 2 years experience in Utilization Review for Insurance or Community Based facility and/or experience in care transition management. * 2 years clinical nursing experience Certification: * Registered or Licensed Practical Nurse required with current unrestricted Washington state license. * Current driver s license EQUIPMENT USED Office equipment, computer, personal vehicle MENTAL & PHYSICAL DEMANDS/WORKING CONDITIONS * Mental Effort: Must be able to work effectively as a member of NPN team; work is detailed and complex with multiple competing priorities, deadlines and internal and external customers * Physical Requirements: Work is primarily in office environment requiring ability to see and hear and communicate as well as operate personal motor vehicle * Working Conditions: Work is performed both in an office setting and at clinic locations; noise level may be moderate or loud on occasion; work may be required outside normal business hours The job description does not constitute a written or implied contract of employment. NPN reserves the right to revise or change job duties and responsibilities as the need arises. Show moreShow less

Keywords: Optum, Tacoma , LPN,Utilization Management, Healthcare , Tacoma, Washington

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