LVN,Utilization Management Compliance

OVERVIEW OF POSITION:

Under the general direction of the Utilization Management Manager, the Utilization Management Nurse is responsible for prospective and concurrent/retrospective review of referrals ensuring regulatory requirements are being met as they relate to language readability and appropriate citation of criteria in Member correspondence. This position is responsible to ensure meeting Member’s needs using nationally recognized UM criteria.

The Utilization Management LVN is responsible for reviewing requests received from providers, using approved protocols and criteria (i.e. State and Federal Law and Regulations Center for Medicare and Medicaid Services (CMS), Title 22, Title 10, Pharmacy and health plan criteria as available, DMHC, DHCS, and MCG guidelines (current edition) as they relate to UM/Health Plan correspondence.

• Responsible for screening and reviewing prospective, concurrent, and retrospective referrals and authorizations for medical necessity and appropriateness of service and care and discussing with Medical Directors.
• Coordinate health care services with appropriate physicians, facilities, contracted providers, ancillary providers, allied health professionals, funding sources and community resources
• Responsible for the prospective review to determine appropriateness of denial, possible alternative treatment, and draft denial language to ensure consistent application of standardized, nationally recognized UM criteria and appropriate use of denial language.

• Coordinate out -of- network and out - of - area cases with member, health plans and Case Management team
• Review’s patient referrals within the specified care management policy timeframe (Type and Timeline Policy).
• Develop and maintain effective working relationships, with physicians and office staff
• Attend in - services, training and meetings relating to job tasks as directed and required
• Demonstrates a thorough understanding of the cost consequences resulting from care management decisions through utilization of appropriate reports such as Health Plan Eligibility and Benefits and Division of Responsibility (DOR)

• Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Performs additional duties as assigned.
• Maintains effective communication with the health plans, physicians, hospitals, extended care facilities, patients, and families.
• Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer service, including quality, care and concern with each and every internal and external customer.

Education:

• High School Diploma or GED
• Graduate of an accredited School of Nursing
• Current, unrestricted RN or LVN license in the state of CA

Experience:

Minimum:

• Over 1 year and up to and including 3 years of clinical experience.
• At least 1 year of recent clinical experience.

Preferred:

• 3 to 5 years of recent clinical nursing experience.
• Previous care management, utilization review or discharge planning experience.
• Managed care experience.
• Experience in an HMO or experience in a Managed Care setting

KNOWLEDGE, SKILLS, ABILITIES:

• Computer literate.
• Knowledge of current standards of patient care.
• Thorough understanding of LVN scope of practice.
• Manual dexterity to use/handle equipment and instruments.
• Ability to effectively communicate and collaborate with physicians, patients, families, and ancillary staff.
• Ability to make sound, independent judgments, and act professionally under pressure.

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