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Full Time
3p - 11p
Job Summary: The Utilization Management Specialist (LPN) will analyze patient records to determine legitimacy of hospital admission, treatment, and appropriate level of care. This position will leverage the algorithmic logic of the UM software to utilizing key clinical data points to assist in status and level of care recommendations.
Minimum Education: Completion of a state approved Licensed Practical Nurse program or registered nurse coursework approved by the Board of Nursing as practical nurse equivalency. Bachelor of Science in Nursing or other related field, preferred.
Licensure, Registration and/or Certification: Valid State of Oklahoma LPN License. ACM/CCM certification preferred.
Work Experience: Minimum 3 years of related experience in an acute care setting. Experience working in electronic health records, preferred.
Knowledge, Skills and Abilities: Strong organizational and time management skills with ability to prioritize multiple tasks and role components. Effective interpersonal, written, and oral communication skills. Demonstrated ability to integrate the analysis of data to discover facts or develop knowledge, concepts, or interpretations. Ability to be detail oriented as required in the examination of numerical data. Strong analytical and data management knowledge. Working knowledge of Microsoft Word, Excel and Access in the preparation of correspondence and reports.
Essential Functions and Responsibilities: Monitors admissions and performs initial patient reviews within 24 hours of admission; and when warranted by length of stay, utilization review plan, and/or best practice guidelines, on a continuing basis. Performs pre-admission status recommendation in Emergency Department or elective procedure settings as assigned, to communicate with providers status guidance based on available information. Maintains thorough knowledge of payer guidelines, familiarity with payer processes for initiating authorizations, and following through accordingly to prevent loss of reimbursement, including the management of concurrent and pre-bill denials. Ensures all benefits, authorization requirements, and collection notes are obtained and clearly documented on accounts in the pursuit of timely reimbursement within established timeframes to avoid denials. Works collaboratively and maintains active communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate management of claims. Facilitates precertification and payor authorization processes as required, ensuring proper authorization has been secured prior to or at the time of discharge for observation and inpatient stay visits to avoid unnecessary denials.
Decision Making: The carrying out of non-routine procedures under constantly changing conditions, in conformance with general instructions from supervisor.
Working Relationships: Works directly with patients and/or customers. Works with internal customers via telephone or face to face interaction. Works with other healthcare professionals and staff. Works frequently with individuals at Director level or above.
Special Job Dimensions: None.
Supplemental Information: This document generally describes the essential functions of the job and the physical demands required to perform the job. This compilation of essential functions and physical demands is not all inclusive nor does it prohibit the assignment of additional duties.
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Utilization Review Management - Yale Campus
Location:
Tulsa, Oklahoma 74136
EOE Protected Veterans/Disability

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