Utilization Management Denial Coordinator LVN

We are searching for a UM Denial Coordinator Licensed Vocational Nurse - someone who works well in a fast-paced setting. In this position, using a collaborative approach, the licensed vocational nurse (LVN) denial coordinator will work with Texas Children's Health Plan (TCHP) medical directors/physician reviewers, network physicians, and network facilities to ensure consistent clinical evaluation and processing of cases not meeting TCHP medical necessity criteria for reasons of medical necessity decisions. Documentation of these decisions and precise record-keeping of notice to Members and network providers is essential in complying with the legal statute and accrediting standards supporting consumer rights.

Think you’ve got what it takes?

Job Duties & Responsibilities

• Create understandably worded letters, with added citation and criteria as applicable
• Ensure member letters are grammatically correct, with appropriate punctuation
• Ensure letters are sent in a timely manner to stay in regulatory compliance
• Generates letters as appropriate (approval, denial, appeal, peer to peer)
• Reviews cases sent by TCHP Utilization Reviewer to establish of criteria application and time frame of processing meet conditions for denial
• Teams with the physician team to identify a strategy for action and to be used as well as a choice of guideline citation/response based on the category of denial
• Validates that authorizations requests are complete and if not, collaborate with UM Reviewers and Medical Directors for correction
• Collaborates with nurse reviewers, medical directors, external physician reviewers, and network providers
• Established integrity of the review process of denial compliance and policies and procedures, managed care and Medicaid through informing and auditing practice
• Ensures the provision of continuity of care needs as required and serves as an advocate on behalf of members and families for out of network authorization approvals
• Identifies problems/barriers/opportunities in the process and provides for resolution, and revision of plans on an ongoing basis
• Analyzes requests against regulatory and decision-making guidelines and benefits allowance.
• Implements action in collaboration with physician reviewer panel and monitors decision making, timeliness, and processing of denials in accordance to regulatory and accrediting guidelines
• Serves as a Flex team – reviews authorization for inpatient and outpatient requests and processes per established criteria and or guidelines for the appropriate benefit, service, and level of care or setting for the delivery of care and or service
• Performs other duties, projects and actions as assigned
• Performs all necessary communication and documentation functions.
• Communicates with internal staff, physicians, hospital representatives, and other providers on status of case review and due process and explanation of rationale, process, and regulatory processing
• Ensures daily monitoring of the denial inquiries
• Re-fax denial notifications or letters, respond to the provider or interdepartmental emails, and document in the referral notes as needed
• Documents all activities and interactions in the electronic and event tracking systems
• Handles inquiries from providers and other departments in a professional manner.
• Collaborates with other reviewers, medical directors, external physician reviewers, and network providers
• Communicates on each case with physicians to establish the best course of action
• Serves as a liaison with the Texas Department of Insurance for independent review requests
• Provides community education for other reviewers on guideline application, changes, and updates
• Maintains flexible schedule for some evenings and weekends to address potential pharmacy denials
• Educates physician reviewers and nursing staff on policies and procedures of the Texas Children’s Health Plan managed care and Medicaid
• Conducts staff and medical director(s) audits on denial activities
• Established integrity of the review process of denial compliance and policies and procedures of the Texas Children’s Health Plan, managed care, and Medicaid through informing and auditing practice
• Performs audits at least annually and quarterly for new hires
• Provides audits on physician and nursing staff based upon audit findings, developing coaching plans based upon findings
• Daily updates denial log information
• Assesses trends in denial types or sources quarterly
• Reports denial activity type and resolution as well as achievement of timely communication standards
• Develops and analyzes quarterly reports for the Clinical Advisory Committee, Quality Improvement Committee, and TCHP Leadership to address outcome data to assist in the identification of improvement opportunities

Skills & Requirements

• Graduation from an accredited School of Vocational Nursing
• LVN - Lic-Licensed Vocational Nurses by the State of Texas
• Required 5 years of Utilization Management experience and a preferred 3 years of Denial or Appeal experience