LPN - Utilization Management (Days) Full Time

Position Summary: 

The Utilization Management (UM) Reviewer, in collaboration with other internal and external offices, payors, and providers and staff, is responsible for the coordinates Utilization Management (UM) processes and requirements for prior authorization/certification for reimbursement of patient care services.  The Utilization Reviewer: • Secures authorization as appropriate • Documents payer authorization • Screens the appropriateness of level of care/service • Facilitates issue resolution with payer sources in collaboration with other hospital departments or clinic offices as appropriate • Demonstrating ongoing competence in payer requirements, as defined collaboratively with Patient Business Services and Care Coordination • Supports data collection and aggregation associated with UM processes and operations.

Education, License & Cert: 

Current LPN licensure or eligibility for licensure required

Experience: 

Minimum of five years clinical experience in an acute health care setting. Must possess strong communication and organizational skills, be able to work independently and to complete work within specified time frames.  Knowledge of health benefit plans and related UM requirements preferred.  Experience with CPT/ICD coding, medical record or chart auditing, and experience in utilization management processes preferred.  Knowledge of computer applications (such as Microsoft word processing and spreadsheets) desirable

Essential Functions: 

1) Validate authorization/certification process for elective short procedures and urgent inpatient care services in collaboration with physician offices, hospital Business Office, Care Coordination and other hospital departments as appropriate. a) Ensures documentation and communication of authorizations and certifications as appropriate. b) Performs routine admission and discharge notification according to payer requirements.

2) Screens the appropriateness of the level of care or service for hospital inpatient admissions and short procedures by translating clinical information to UM requirements (using identified criteria).

a) Collaborates with Case Managers to distribute admission reviews daily.

b) Documents UR findings in appropriate computer system and screen

c) Utilizes reports and other mechanisms to identify cases for UR screening and follows procedures for follow up as necessary.

3) Proactively researches case findings related to payer audits of UM decisions and supporting documentation to complete the revenue cycle process; coordinates as necessary with the hospital Business Office, physician offices, Care Coordination, Medical Director and other hospital departments as appropriate.

a) Serves as liaison with payers, hospital Business Office, physician offices, Care Coordination and other hospital departments as appropriate for resolution of issues or questions.

b) Collaborates with the hospital Business Office, physician offices, Care Coordination and other hospital departments as appropriate to track and monitor the status for denials and appeals.

c) Collects and aggregates clinical, financial, and variance data to support the identification of opportunities for cost savings and efficient resource management/utilization.

4) Participates in performance improvement and educational activities.

a) Serves as an educational resource to other members of the healthcare team with regards to changes in reimbursement, payers, and/or utilization requirements.

b) Participates in departmental long‐range planning to meet the needs identified through utilization management activities.

c) Demonstrates appropriate problem solving and decision making skills.

d) Maintains the required 8 hours of continuing education per year.

Other Duties: 

1. It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position.