LVN- In Office

This position is responsible for implementing and coordinating all utilization management functions relating to pre-certification of outpatient services. The LVN Case Manager in this capacity is responsible for coordinating authorizations and notifications.Provides workflow, direction, organization and monitoring of authorizations/utilization management. Coordinates and tracks authorization files between Authorization Coordinators and Physician reviewer.

Essential Functions and Responsibilities of the Job

• Clear understanding of managed healthcare, utilization management
• Possess knowledge of applicable regulatory standards and is able to prepare for audits based upon these standards
• Ability to maintain compliance and turnaround time standards for all UM assignments
• Provide excellent customer service to our members
• Communicate effectively with a professional attitude.
• Be responsible and accountable for all assignments and deliverables
• Follow company policies, procedures and directives
• Interact in a positive and constructive manner
• Prioritize and multitask in a fast-paced work environment

Essential Job Outcomes

• Inputs all information in referral system and ensures that all information is accurate.
• Process referral authorization from providers in a timely manner, by utilizing established protocols.
• Faxes back to requested provider information needed if not received.
• Gathers and assess relevant documentation to compare with MCG/UM Criteria.
• Communicates with Utilization Physician Reviewer for follow-up and resolution of authorization referrals.
• Interacts effectively with providers, physician reviewers, and other departments using strong verbal and written communication skills on an on-going basis
• Applies UM criteria appropriately to authorization requests
• Apply Timeliness Standards to processing of referrals (ICE Timelines Grids)
• Review and update authorizations as needed
• Requests medical records or other information as needed to justify referrals
• Other duties as assigned