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Utilization Review Nurse (Lpn)
Company | 1199SEIU Benefit and Pension Funds |
Address | , New York |
Employment type | FULL_TIME |
Salary | |
Expires | 2023-09-14 |
Posted at | 9 months ago |
Responsibilities
- Departmental Policy and Procedures, Reference Guides, Checklists and Milliman Care Guidelines
- Process prospective, concurrent, retrospective Utilization Management (UM) medical requests and 1st level appeal, adhering to Fund’s established timeframes
- Maintain appropriate documentation of all services in keeping with all confidentiality and HIPAA regulations
- Perform special projects and assignments as directed by management
- Maintain, monitor, and review the UM workflow to ensure coverage determinations are processed efficiently, timely, accurately, and consistently
- Tro ubleshoot and interve ne with difficult vendors/providers and assist with urgent/expedited/complex cases that require management level problem solution.
- Work closely with medical advisors and management team for escalated complex UM requests
- Ensure compliance with UM determinations, retro reviews, appeals, and case management programs according to SPD, time frames, clinical policies, and operational workflows
- Identifying gaps of care, need for specialized services and equipment outlining action plan with applicable disciplines and vendors
- Authorize vendor services based on skilled need and or medical necessity applying relevant
- Conduct internet research to retrieve data for complex cases
- Establishes proactive approach to problem solving
- Be a liaison with other departments and establish and maintain communication links with other areas of the Fund.
- Work within Document Management System (DMS) and follow workflows for assigned concurrent, retrospective UM medical requests and 1st level appeal, based on areas of expertise
- Comply with UM productivity standards, track, and report regularly
Qualifications
- Internet research for investigating and retrieving pertinent data for complex inquiries.
- Working experience utilizing Milliman Care Guidelines
- Strong clinical skills background.
- New York State LPN License required
- Minimum two (2) years of Utilization Management experience; and two (2) years working in a clinical setting, such i.e., inpatient hospital and pertinent outpatient services (i.e., homecare vendors) required
- Ability to work in fast-paced high volume work environment, maintain professional manner and presentation, multi-task, establish priorities, delegate, meet deadlines and follow through on assignments
- Intermediate level Microsoft Word, Excel, and Outlook.
- Must have the ability to exercise judgment and discretion in establishing and maintaining good work habits and relationships, maintaining the confidentiality of the position in all dealings
- Effective time management skills.
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