Medica is excited to share this permanent opportunity with you! Our client is looking for an LVN UM Case Manager to join their team! They offer competitive pay, great benefits and tuition reimbursement!
Overview
Responsible for reviewing proposed hospitalization, home care, and
inpatient/outpatient treatment plans for medical necessity and efficiency with coverage
guidelines. The UM Nurse determines medical appropriateness of inpatient and outpatient services
following evaluation of medical guidelines and benefit determination.
Responsibilities
1. Responsible for the daily review and processing of referral authorizations in accordance to
turnaround time (TAT) standards set by ICE/Health Plan
2. Works collaboratively with Hospitalists, hospital partners, and care teams to provide
holistic patient care that is focused on high quality in a cost effective
3. Monitors ongoing services and their cost effectiveness; recommending changes to the
plan as needed using clinical evidence-based criteria – Milliman, Interqual, CMS, National
Recognized American Academy of Specific Specialty, Health Plan specific criteria.
4. Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to
drive decision-making
5. Maintains up to date knowledge of rules and regulations governing utilization
management processes;
6. Input data into the Medical Management system to ensure timeliness of referral
processing.
7. Verifies member benefits and eligibility upon receipt of the treatment authorization
Qualifications
1. Current valid License as a Licensed Vocational Nurse.
2. Minimum of 2 years of managed care experience
3. Demonstrated ability to work with automated systems, including electronic medical
records and MS Office products such as Word, Excel and Outlook.
4. Excellent customer service; ability to be an effective communicator
5. Knowledge of federal, state and other applicable standards for clinical practice for
assigned area(s) of responsibility.
6. Ability to work collaboratively with diverse individuals and situations, including strong
problem solving and conflict resolution skills
INDMED