Lvn, Utilization Management Compliance

Healthcare Partners Costa Mesa , CA 92626

Posted 4 months ago

OVERVIEW:

Responsible for educating the individual Care Management regional departments on the regulatory requirements from all regulatory organizations (CMS, NCQA and contracted Health Plans) and for assisting the regions in maintaining regulatory compliance of Care Management processes. Acts as a resource in the areas of referral processing, denial letter processing and clinical decision-making.

ESSENTIAL FUNCTIONS:

  • Conducts regional-based training to educate Care Management staff on health plan regulatory procedures and processes.

  • Acts as a central resource with regards to regulatory requirements from participating regulatory agencies, health plan clinical review criteria and HMO benefits.

  • Contributes pertinent utilization-related materials to the departmental intranet site.

  • Assists in preparing the department for annual health plan audits.

  • Conducts review of procedures related to referral processing including oversight of denial letter processing.

  • Performs reviews as needed on other related Care Management processes including retrospective and prospective review of referrals and appeals review.

  • Demonstrates a thorough understanding of the cost consequences resulting from Care Management decisions through utilization of appropriate reports (Health Plan Eligibility and Benefits, Division of Responsibility (DOR)).

  • Communicates authorization/denial for services to appropriate parties including patient (or agent), attending/referring physician, facility administration and HCP Claims Department as necessary.

  • Participates as requested in assigned Care Management Committee meetings. Addresses pertinent regulatory information to all members of the health team when appropriate.

  • Contributes to current Care Management programs within the policies and procedures set by the Care Management Department.

  • Contributes to team decisions in the development and enhancements to the Electronic Referral Management system.

  • Maintains effective communication with the health plans, physicians, hospitals, extended care facilities, patients and families.

  • Initiates or oversees data entry into IS systems within the parameters of Care Management policies and procedures. Maintains accurate and complete documentation of services requested including CPT code, ICD-9, referral type, date, etc.

  • Uses, protects, and discloses HCP patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.

  • Performs additional duties as assigned.

EDUCATION:

  • 1 or 2 years of post-high school education or a degree from a two-year college.

  • Graduation from an accredited school of Nursing.

  • Current California LVN license.

EXPERIENCE:

Minimum:

  • Over 1 year and up to and including 3 years of clinical experience.

  • At least 1 year of recent clinical experience

Preferred:

  • 3 to 5 years of recent clinical nursing experience.

  • Previous care management, utilization review or discharge planning experience.

  • Managed care experience.

KNOWLEDGE, SKILLS, AND ABILITIES

  • Computer literate.

  • Knowledge of current standards of patient care.

  • Thorough understanding of LVN scope of practice.

  • Manual dexterity to use/handle equipment and instruments.

  • Ability to effectively communicate and collaborate with physicians, patients, families and ancillary staff.

  • Ability to make sound, independent judgments and act professionally under pressure

icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
LVN Float Pool (Costa Mesa CA US)

Hoag Memorial Hospital Presbyterian

Posted 1 week ago

VIEW JOBS 10/9/2019 12:00:00 AM 2020-01-07T00:00 Hoag Medical Group (HMG) is building a stronger more agile “Float Pool” staffing model, in an effort to improve patient quality and deliver better coordination of care.  Our Float Pool will be comprised of team members who embody the culture and the mission, vision, values of Hoag.   Under the direction of a RN Clinic Manager, provides care within the scope of the Vocational Nurse Practice Act and regulatory standards. Assists in the planning, implementation and evaluation of patient care. Participates in maintaining a safe patient care environment. Assist with the care and maintenance of department equipment. Complete and accurate charting of patient records. Complete and accurate record keeping of equipment and quality measures. Assist team in direct and indirect patient care as assigned by department. The patient population includes young adults to geriatric patients with a variety of medical-surgical disorders.   The LVN must collaborate with other disciplines of the health care team to ensure the delivery of care across the continuum, providing timely, safe and quality care. Responsible for providing a safe, HIPAA compliant environment for the patient and the staff. Demonstrates competence and sensitivity in caring for multicultural patients/families by adapting the plan of care based on cultural needs identified. Demonstrates an ability to work in a multicultural team environment and is respectful of the cultural diversity of the workforce and the patients served. Participates in continuous quality improvement process. Demonstrates effective communication, interpersonal skills, organizational ability, knowledge of proper body mechanics, safety measures and infection control, ability to follow instructions, knowledge of section specific test information and instrumentation may be required.   Essential Functions Specific duties and responsibilities include, but are not limited to: * Highly skilled and flexible individuals includes those who can float between HMG clinics and work in various specialties (pediatrics, internal medicine, emergency medicine, family medicine), as well as those who can move between clinic locations. * Utilize as our “Acquisition Response Team”. Team members will provide staffing coverage for orientation, training and onboarding of new HMG employees. * Team members will serve as mentors, trainers, advisors and cultural ambassadors to help new offices get set-up and assimilate into our growing network of clinics. * Float Pool will be our “go-to” resource team to cover active/rolling leaves, transfers, separations, PTO requests, unexpected sick leave, etc. * Provide consistency and stability of resources for known demand (when core staff are unavailable to take a patient) and the flexibility to adjust based upon the specific needs for a particular day/shift * Weekends and evening shifts may be required.   Demonstrates competent knowledge, based on hospital policies, procedures and standards, in the following: * Demonstrates an ability to organize and incorporate new routines, procedures and skills. * Demonstrates skill in the use of equipment and devices pertinent to treatment, procedures and practices. * Communicates changes in the patient's condition to the registered nurse and the physician directing the care of the patient. * Follows procedure in the identification of patients prior to implementing any procedures, interventions, etc * Provides appropriate information for all patient procedures and ensures patient/significant other understanding prior to start of procedure. * Responds to emergency situations in a timeframe appropriate to the needs of the patient. * Administers medications with the ability to assess the indication appropriate dosing and effects of the medication administered for the patient. * Correctly collects, handles, and labels specimens utilizing Standard Precautions, as well as documenting in the patient record. * Adheres to Infection Control policies and procedures, follows Standard Precautions and specific isolation precautions for the prevention and spread of blood borne pathogens and other communicable diseases * Appropriately implements prescribed interventions to ensure pain management for the patient * Recognizes that ethical/legal/medical dilemmas exist in the nursing practice and confers with the appropriate resource personnel when making ethical nursing decisions. * Provides education with respect to the proper educational ability and level for the patient population. Incorporates available educational material into patient/significant other teaching and documents understanding in patient record. * Communicates to physician nutritional needs/problems for the patient. * Provides continuity of care through implementation/utilization of the Plan of Care for the patients * Clinical Care: Ensure that quality patient care is delivered to all patients on a 24-hour basis, and the unit is maintained in accordance with professional and regulatory standards and the philosophy and goals of Hoag. Unit/Department Specific: Duties include performance of all medical back office functions including but not limited to: * Collecting and documenting patient histories, vital signs, current medications, history of current illness, allergies. * Equipment preparation and maintenance. * Appointment scheduling, scheduling of diagnostic testing. * Obtain insurance authorizations as necessary for diagnostic tests. * Provide patients and caregivers with pre-procedure instructions. * Assist physician in rendering treatment as necessary * Must be able to assist front office staff in front office functions when necessary. * Triages patient calls and reports patient status to physician. * Performs other duties as assigned.   Education, Training and Experience Required: * High School Diploma or equivalent * Current LVN License from the State of California. * BLS certification required. * Minimum one (1) year of experience in an acute care facility   Skills or Other Qualifications Required: * Basic keyboarding skills at 35 WPM. * Basic knowledge of Microsoft Office Suite, including Outlook, Word and Excel. * Excellent communication skills; customer focused; excellent attention to detail; able to prioritize tasks and meet deadlines; strong interpersonal skills; able to work in a team environment. * Proven ability to interface with all customer levels (physician, Organization staff, insurance companies, patient and family members) * Strong trouble-shooting and problem-solving skills. * Demonstrates effective communication, interpersonal skills, organizational ability, knowledge of proper body mechanics, safety measures and infection control, ability to follow instructions, knowledge of age of population served, and additional skills and knowledge of equipment may be required for hire into some patient care departments.   Preferred: * Knowledge of registration and order entry systems. * Knowledge of patient scheduling and insurance verification and authorization. Intermediate knowledge of Microsoft Office Suite, including Outlook, Word and Excel Hoag Memorial Hospital Presbyterian Costa Mesa CA

Lvn, Utilization Management Compliance

Healthcare Partners