Job Title: Utilization Review Analyst II – Licensed Practical Nurse
Classification: Utilization Review Analyst (LPN). Reports To: Director of Health Benefit Operations. Department: Administration. Compensation: Hourly/Non-Exempt – Commensurate with Experience. Location: 25790 Commerce Drive, Madison Heights, MI 48071.
Responsibilities
Initial clinical evaluation and screening of utilization management patients.
Ongoing objective evaluation of key aspects of patients’ care.
Periodic review of patient records.
Identify variations in care and provide data to support correction of over‑ or under‑utilization.
Provide clinical support to non‑clinical staff.
Perform utilization reviews in accordance with medical policy and regulations.
Obtain and review medical necessity and supporting information, including treatment plan requests.
Validate physician orders to ensure appropriate and cost‑effective services.
Process requests for durable medical equipment, orthotic/prosthetic, enteral nutrition, and medical supplies.
Document review information and case notes in the information system.
Serve as a resource for clinically related questions.
Participate in research, review, and revision of medical policies on an annual basis.
Perform utilization follow‑up contacts with patients.
Coordinate with the clinical team to oversee the utilization management program, including developing, administering, and reporting on audit compliance metrics.
Perform administrative duties: receive, log, and file documentation, reports, and records.
Other duties as assigned by management.
Comply with all company information security policies and responsibilities.
Qualifications
Active State of Michigan Nursing license (LPN) without contingencies.
Minimum 2 years experience in durable medical equipment, managed care, or utilization management.
Excellent clinical assessment skills.
Ability to work with minimal supervision.
Effective communication skills.
Clear and concise written correspondence.
Teamwork with internal and external stakeholders.
Ability to establish priorities and work within time constraints.
Strong organizational, task, and prioritization skills.
Ability to identify medical utilization trends.
Computer literate.
Company
Northwood plays an integral role in health plan benefit administration for durable medical equipment, prosthetics, orthotics and medical supplies, serving auto and workers’ compensation clients and PIP claimants.