LVN Prior Authorization (Temp, Remote)

Description:

The role of the Nurse Reviewer is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization specialty referral requests as well as acute inpatient admission The Nurse Reviewer will review for appropriate care and setting, and following guidelines/policies, will approve services when indicated If not indicated, Nurse Reviewer will forward requests to the appropriate physician or medical director with recommendations for other determinations, ensuring that the member is receiving the appropriate quality care in a preferred setting, while making sure regulatory guidelines are followed • Work in collaboration with the Regional Medical Director to thoroughly review member referral history and anticipated needs in an effort to avoid admission • Responsible for identifying possible TOC cases for new members with high cost diagnosis • The Nurse Reviewer will be responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified patients during an acute care episode as well as prior authorizations (particularly those with facility components) • Identifying the appropriate facilities in order to provide the highest level of care, in the most efficient manner, while utilizing only the resources necessary for that episode of care • Understand, promote and review with the principles of medical management to facilitate the right care at the right time in the right setting • Communicate effectively and interact with providers, staff and health plans daily or as indicated regarding medical management and referral authorization issues • Maintain a working relationship with PACM colleagues, the pre-auth coordinator team, high-risk nurse case managers, inpatient nurse case managers, medical directors, and network management • Research alternative care plans and when necessary, assist in the routing of members to the most appropriate care/setting, in order to provide right care/right setting • When necessary, act as liaison between the case managers, UM coordinators, contracted providers (PCPs/specialists/ancillary), and the members/families • Perform case reviews base on key screening outpatient indicators, and evaluate the PCP submitted plan of care for its completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to standard evidence-based or consensus guidelines, and health plan and CMS guidelines and/or medical policies • Maintain regulatory Turnaround Time Standards per regulatory guidelines • Document accurately and completely all necessary information in authorization notes • Approve those approvable requests as indicated based on protocols • Forward those authorization requests needing physician review with an accurate summary of the case, and recommendation • Understand all applicable capitation contracts and how they apply to review duties • For those PACMs involved in DME, understand the contracts, and need to review rental vs. purchase approvals, and continued use so that equipment is picked up when needed • When appropriate, coordinate and review for medical necessity and appropriate utilization any ancillary professional services, i.e. (home health, infusion, PT, OT, ST, etc.) • Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner • Participates in "service recovery" through follow-up with an upset patient or provider, gathering information, and demonstrating empathy • Identifies network needs and report to management for potential contracting opportunities • All other duties as directed by management

Skills:

Prior authorization, Utilization review, utilization management

Top Skills Details:

Prior authorization,Utilization review,utilization management

Additional Skills & Qualifications:

Qualifications Graduate from an accredited Registered Nursing Program or Licensed Vocational Nursing Program Current California Licenses Minimum of 1 year acute experience Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management Knowledgeable in computers and MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point) Ability to deal with responsibility with confidential matters Ability to work in a multi-task, fast-paced, high-stress environment

Experience Level:

Intermediate Level

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

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At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

• Hiring diverse talent

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