LVN Utilization Review

Title: LVN Utilization Review

Location: Fountain Valley

Department: Outpatient Utilization Management

Status: Per-diem

Shift: Days

Pay Range*: $40.00/hour

At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. Memorial Care stands for excellence in Healthcare. Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.

Position Summary

Under minimal supervision and using clinical experience, evidence-based knowledge and in collaboration with our physicians, to process clinically appropriate care management referrals.

Essential Functions and Responsibilities of the Job

1.Along with physician hospitalists / PCPs / Specialists, leads and coordinates activities of interdisciplinary treatment team required to make complex clinical, benefit and network decisions.

2.Analyze data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with MemorialCare Medical Foundation strategic goals and objectives.

3.Apply Utilization Review Management process to ensure continuity of care throughout the health care continuum including review and authorization of services applying evidence-based guidelines and per MemorialCare Medical Foundation policy.

4.Assures review turnaround times adhere to timeliness standards set by contracting and regulatory requirements and established productivity and quality guidelines.

5.Decisions and documentation demonstrate prudent utilization of resources, identifies for potential cost reduction; promote quality care and comply with regulatory guidelines needed to maintain delegated status from contracted health plans.

6.Assists with developing corrective action plans, create policies and design workflows that operationalize improvements identified through data and leadership analysis.

7.Documents decisions that demonstrate independent judgment, critical thinking and application of complex managed care regulations including but not limited to benefit structures, health plan coverage, medical necessity, network contract, financial responsibility and care management.

8.Implement and maintain systems and processes that meet various regulatory requirements.

9.Interprets and applies delegation agreements, divisions of financial responsibility, contracted provider lists, evidence of coverage, health plan operations manuals, and MemorialCare Foundation policy.

10. Independently research and determine the information necessary to satisfy specific business and regulatory medical management requirements. Initiate and complete the denial process for all services deemed to be non-covered benefits or not medically necessary.

11. May be called upon to participate in regulatory compliance audit requirements and activities/committees including but not limited to Utilization Management, Quality Improvement and Performance Improvement.

12. Maintain and demonstrate a complete understanding of own scope of practice of licensure and education level.

13. Monitors utilization and provides recommendations for improvement against established industry standards and performance measurement metrics.

14. Works with Managers to oversee approval, denial and appeal process, including implementation of appropriate denial letter language to meet regulatory standards.

15. Participates in Contracting and Provider Relations activities as necessary to develop and maintain provider networks.

16. Subject to standard medical management performance measurements for specific area/team including but not limited to referral turnaround times, volume, denial language and overturn rates.

17. May be required to travel during shift for meetings and staff oversite.

18. May be required to work remote to meet business needs for regulatory compliance.

• Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare-that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there's more...Check out our MemorialCare Benefits for more information about our Benefits and Rewards.

Experience

• Minimum 2 years of utilization / care management experience applying evidence-based criteria (i.e.: Milliman, Interqual); CMS; Health plan medical policy / clinical coverage guidelines required

• Experience performing medical management (UM) in electronic referral application preferred.

• Navigation of Share Point or equivalent experience navigating internal company intranet preferred.

• 2 years' work experience in Microsoft Word, Microsoft Excel and Microsoft Outlook preferred

Education

• California Licensed Vocational Nurse required