Utilization Review LVN
Dignity Health Medical Foundation, Rancho Cordova, California
As a Utilization Review (UR) LVN, you will use clinical judgement in providing utilization management (UM) services. The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary. You will assist in determining appropriateness, quality and medical necessity of referral requests using pre-established guidelines. This position supports the Medical Group in effective management of the managed care patient.
Responsibilities may include:
- Conducts pre-authorization referral reviews, following workflow as written, document criteria to make determination or recommendation and process the referral in a timely manner.
- The LVN supports the quality programs within the Department through participation in projects, reviews and compliance with policies and practices.
- The LVN provides appropriate support to co-workers, leaders, physicians, referral sources and other departments during all work activities.
Job Requirements:
- Minimum Qualifications:
- 3 years Managed Care/Utilization Management (UM) experience. 5 years LVN experience.
- Clear and current CA LVN license.
- Knowledge of health plans. Medical specialty procedures and diagnoses.
- Strong knowledge nursing requirements in a clinical setting. Knowledge of utilization management programs as related to pre-set protocols and criteria.
- Ability to work within an interdisciplinary structure and function independently in a fast paced environment while managing multiple priorities and meeting deadlines.
- Ability to apply clinical judgment to complex medical situations and make quick decisions.
- Ability to read and interpret benefit contract specifications.
- Ability to understand and follow established criteria and protocols used in managed care functions.
- Strong organization skills.
- Effective telephone and computer data entry skills required.
- Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses.
- Preferred Qualifications:
- General knowledge of UM and Managed Care preferred.
- Use of InterQual guidelines preferred.
- Experience at meeting deadlines by prioritizing work flow preferred.
- Physician group experience preferred.
- Knowledge of California health plans and differences between commercial and advantage plans preferred.
- Familiarity with business practices and protocols with ability to access data and information using automated systems preferred.