Licensed Vocational Nurse Utilization Review Per Diem Days BHS

Summary

The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position integrates national standards 
for case management scope of services including:

• Utilization Management services supporting medical necessity and denial prevention 
• Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient
• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy 
• Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits
   

The individual’s responsibilities include the following activities:

a) accurate medical necessity screening and submission for Physician Advisor review,

b) securing and documenting authorization for services from payers,

c) managing concurrent disputes,

d) collaborating with payers, physicians, office staff and ancillary departments,

e) timely, complete and concise documentation in the Tenet Case Management documentation system,

f) maintenance of accurate patient demographic and insurance information

 g) identification and documentation of potentially avoidable days,

h) identification and reporting over and underutilization,

i) and other duties as assigned

Qualifications

MINIMUM EDUCATION: Graduate of an accredited School of Nursing 
PREFERRED EDUCATION: Associates in Nursing 
MINIMUM EXPERIENCE: 2 years acute hospital or behavioral health patient care experience with at least 1 year utilization review in an acute hospital or commercial/managed care payer setting.
PREFERRED EXPERIENCE: 1 year hospital acute or behavioral health case management experience.
REQUIRED CERTIFICATIONS/LICENSURE: Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active LVN/LPN license for state(s) covered.
PREFERRED CERTIFICATIONS/LICENSURE: Accredited Case Management (ACM)
REQUIRED COURSES/ COMPLETIONS:

• Must complete Tenet’s InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better)
• Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire.
• Orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQual, Utilization Management, and other topics specific to case management

#LI-NS1
Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law

The individual’s responsibilities include the following activities: a) accurate medical necessity screening and submission for Physician Advisor review, b) securing and documenting authorization for services from payers, c) managing concurrent disputes, d) collaborating with payers, physicians, office staff and ancillary departments, e) timely, complete and concise documentation in the Tenet Case Management documentation system, f) maintenance of accurate patient demographic and insurance information, g) identification and documentation of  potentially avoidable days, h) identification and reporting over and underutilization, i) and other duties as assigned.

Utilization Management: Completes and sends admission and concurrent reviews with clinicals for patients whose payers have an authorization process. Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management. Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes. Identifies and documents Avoidable Days using the data to address opportunities for improvement. Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, and discharge)