Utilization Review LPN

Utilization Review LPN
Department: Case Management

What if you had the opportunity to make a difference? Carroll County Memorial Hospital’s role is to improve the health and well-being of the residents and visitors to Carroll County and surrounding counties, by providing quality, compassionate, cost effective and convenient health care through community leadership and in collaboration with other healthcare organizations which serve our communities.

The Utilization Review Licensed Practical Nurse (LPN) is to support the hospital's utilization management program by assisting with the review and monitoring of patient care services to ensure appropriate utilization of healthcare resources, compliance with regulatory and payer requirements, and accurate clinical documentation. The Utilization Review LPN collaborates with providers, nursing staff, case management, and payers to facilitate timely authorizations, support medical necessity determinations, and promote efficient, high-quality patient care while helping to optimize reimbursement and organizational performance.

Full-Time Hourly Position

Physical Location:
309 11^th St.
Carrollton, KY 41045

The Job You Will Perform:

• Ensures cost effective patient care services. Provides specific recommendations to care team members regarding cost-effective alternatives
• Assess admission criteria and length of stay, applying standardized clinical guidelines such as MCG to justify care levels
• Issues pre-authorizations for procedures, medications, and durable medical equipment by providing clinical information to insurance carriers
• Collaborate with physicians and other healthcare providers to discuss patient care plans and ensure alignment with coverage policies
• Identify and refer cases to case management or social work for complex discharge planning needs
• Facilitate communication between medical staff and payers to resolve issues related to treatment plans and reimbursement
• Prepare and submit clinical appeals to insurance companies when services are denied, providing documentation to support medical necessity
• Advocate on behalf of patients to identify, address, and intervene on physical and psychosocial health care needs
• Analyze care needs of patients and monitors progress toward desired outcome goals and tracks and analyzes clinical and financial data to support clinical decision-making
• Upon admission, develop an initial individualized Case Management plan through assessment data, identification of resources, and post-acute options beginning with admission
• Communicate and collaborate with patient/family/ significant other, and all members of the care team throughout the continuum. Begin appropriate referrals as indicated, i.e., Social Services, Physician Advisor, and Medical Director
• Monitor and evaluate daily patient’s progress via chart review to ensure cost/benefit value, continuity of care, Case Management Plan modification, patient/family satisfaction and compliance. Intervene immediately with Team Leader or appropriate team members if clinical or system variances are identified that delay progress through the course of care
• Collects appropriate data and completes tracking/trending logs in a timely manner
• Communicates abnormal lab results, questionable health history and physical findings to the appropriate Nursing personnel

The Qualifications, Skills and/or Knowledge You Bring:

• Kentucky Licensed Practical Nurse required; CCM preferred
• Minimum of two years direct clinical experience required
• Minimum of two years experience in Utilization, Quality, or Case Management preferred
• Knowledge of acute care regulatory/accreditation requirements, discharge planning and Quality Improvement experience preferred
• Data analysis and interpretation skills. Strong organizational and prioritization skills needed
• Dependable, self-directed and pleasant. Adaptable and flexible to meet patient/family and department/facility needs

The Benefits You Will Enjoy:
Carroll County Memorial Hospital offers a benefits package to eligible employees that includes welfare and retirement plans including Medical, Dental, Vision, Life insurance, Flexible Spending Accounts, Short-term and Long-term Disability, 401(k), Company-funded retirement contributions, and Paid Time Off.

The Company You Will Join:
Carroll County Memorial Hospital strives to uphold our Values of Respect, Compassion, Excellence, Stewardship and Justice each day to ensure we provide the best possible services to the communities we serve.

Carroll County Memorial Hospital is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.
If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please email humanresources@ccmhosp.com