LPN/Utilization Review Specialist - Case Management - University - Full Time - Days Job

Summary

The Utilization Review Specialist, through the use of documented medical criteria and nursing knowledge and under the supervision of the Manager is responsible for coordinating and monitoring inpatient services for all aspects of patient care that pertains to hospital admission.  The Utilization Review Specialist monitors healthcare services that are medically necessary, appropriate, effective and cost efficient according to hospital standards.  The Utilization Review Specialist also works with the physicians to help assure appropriate documentation.  Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

Education/Experience/Licensure

 

Education/Formal Training

Work Experience

Credential/Licensure

 

REQUIRED:

Graduate of a vocational nursing program.

Five (5) years clinical experience as LPN.

 

Current licensure as LPN in state of Tennessee.

 

 

PREFERRED:

N/A

 

Acute care experience preferred.

 

Prior experience in utilization management, care coordination, care facilitation and discharge planning preferred.

 

N/A

 

SUBSTITUTIONS ALLOWED:

N/A

N/A

N/A

Knowledge/Skills/Abilities

• Positive working relationship and excellent interpersonal skills in working with physicians required.
• Excellent written and verbal communication skills.
• Ability to plan and schedule tasks and to maintain control of own workflow.
• General PC skills.
• Previous experience with Care Management/Utilization Management software packages preferred.
• Effective interpersonal relationship skills.

Key Job Responsibilities

• Assesses opportunities to decrease fragmentation in health care delivery system; improves utilization of resources to improve quality of care. Assesses all patients to determine medical necessity for admission and continued stay in the appropriate level of care while remaining cognizant of the average length of stay per diagnosis for all patient populations.
• Interacts with payors for cases requiring advanced clinical knowledge and detailed knowledge of patient status.  Provides clinical support personnel with appropriate clinical assessment to assure timely completion of payor reviews.
• Demonstrates initiative in identifying and pursuing opportunities for self-improvement and enhancement of professional competency.
• Demonstrates effective customer relation skills, promotes a positive work environment and contributes to the overall team effort.  Establishes a good working relationship with physicians, patients and other members of the patient care team.
• Understands, applies and supports department/hospital policies, procedures and standards.

Physical Requirements

• Non-invasive patient contact.
• Must be able to read, write and communicate both orally and in writing to individuals in the healthcare field.
• Ability to stand, walk and sit in one place periodically throughout the shift.
• Good balance and coordination.