Utilization Review LVN

Are you looking for a job to utilize your knowledge as an LVN? Apply today for an opportunity to work with a wonderful company in Kern County!

Essential Functions and Responsibilities

• Conducts pre-authorization referral reviews, follows workflow as written, document criteria to make determination or recommendation, and process the referral in a timely manner.
• Manages assigned queues on a daily basis working oldest referrals first to ensure 98% compliance with ICE timeframes.
• Follows job work aid in a sequence of performing the job, including checking eligibility on health plan websites. Demonstrates 100% accuracy of identification of DHMG-IE/DHPN-IE members before referral review is initiated.
• Preps case thoroughly, concisely, and clearly for physician review. Researches EMR, criteria, medical policy, and past history of members to detail cases cleanly for MD in 95% of the cases.
• Communicates findings to physician and member in accordance with all regulatory and DHMG-IE/DHPN-IE guidelines and documents same in 95% of cases.
• Recommends and coordinates interventions to facilitate high-quality, cost-effective care, monitoring treatment, progress, and outcomes of patients.
• The Nurse assists in the refinement/improvement of the utilization management program by participating in continuous process improvement endeavors.
• The Nurse responds promptly and with courtesy to inquiries from claims, other hospitals, other departments seeking assistance, member services, management, physicians and others by either resolving the situation or referring it appropriately. Documentation is completed for all issues to create a record.

Minimum Qualifications

• Minimum 3-5 years of Healthcare experience with general knowledge of Utilization Management and Managed Care.
• Graduate of an accredited school of nursing: Licensed Vocational Nursing.
• Licensure: California LVN license
• Preferred 5-7 years of experience in combination of utilization management, prior authorization or acute/sub-acute care experience.
• Understanding of assessment tools such as InterQual, MCG, and DRGs; Direct experience working with Managed Care and Medicare/Medicaid Regulations.
• Strong knowledge of nursing requirements in a clinical setting.
• Knowledge of utilization management programs as related to pre-set protocols and criteria.
• Must be able to communicate clearly and concisely with all levels of individuals, sometimes in stressful situations
• Able to stay organized and flexible in a work environment with multiple assignments and changing priorities.
• Ability to perform job functions independently and with minimal supervision.