Utilization Management LPN

REPORTS TO: UM Supervisor

LOCATION: Allegiance office or off-site

FSLA STATUS: Non Exempt

POSITION RESPONSIBILITIES:

The UM LPN will assist in coordinating requests for admissions and service procedures. The UM LPN is responsible for promoting the quality and cost-effectiveness of medical service and admission reviews by applying clinical judgement in accordance with medical policies and national guidelines to determine authorization/certification of said service/admission. The UM LPN ensures that all reviews are completed in a timely fashion to meet contractual requirements. This position may also include participating in team functions such as committees, QA team evaluations, and preceptorships. The incumbent is expected to conduct all communication and assignments professionally with peers, supervisors, subordinates, vendors, customers, and the public.

ESSENTIAL JOB FUNCTIONS:

Essential job functions include the following. Other functions may be assigned as business conditions change:

• Able to initiate phone calls requesting information for admissions and continued stay reviews.

• Evaluates and authorizes the medical necessity of Services requested. utilizing, but not limited to the below criteria:

• American Society of Addiction Medicine (ASAM)
• MCG
• Cigna Medical Policy
• Plan Language
• Internal addendum criteria

• Coordinates escalation of reviews to Medical Directors as needed.

• Screens for and initiates referrals to Case Management.

• Able to effectively initiate and return telephone messages independently.

• Provide accurate information to callers as evidenced by software entry/documentation.

• Compliance with protocols and QA requirements.

• Manage the processing of temporary provider.

• Preparation of forms, faxing, copying.

• Organizion of files and referance materials.

• Ability to operate typical office equiptment and working knowledge of basic office practices.

• Contributes to daily workflow with regular and punctual attendance.

NON-ESSENTIAL JOB FUNCTIONS:

• Performs related or other assigned duties as required or directed.

PHYSICAL WORKING CONDITIONS:

Physical requirements are representative of those that must be met to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Sitting 80% Reaching Minimal Standing 10% Manual Dexterity Ability to type/keyboard Walking 10% Telephone High Degree Kneeling As needed Computer Screen High Degree Bending As needed Lifting 25 pounds

JOB SPECIFICATIONS:

To perform this position successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education, Licensure, Experience:

• Current licensure as a Licensed Practical Nurse LPN or Licensed Vocational Nurse LVN.

• At least one year clinical experience

Other Experience:

• Must possess organizational skills and the ability to prioritize multiple tasks, attention to detail and follow through to completion.

• Excellent oral and written communication skills required.

• PC skills, including Windows and Word. Ability to learn all functions of the claims processing software as is necessary for claims processing and adjudication. Must be able to adapt to software changes as they occur.

• Excellent listening skills.

• High level of interpersonal skills to work effectively with others.

• Ability to organize and recall large amounts of detailed information.

• Ability to read, analyze and interpret benefit summary plan descriptions, insurance documents, plan benefits, and regulations and make appropriate applications to specific situations.

• Thorough knowledge of claims processing procedures and requirements.

• Ability to project a professional image and positive attitude in any work environment.

• Ability to comply with privacy and confidentiality standards.

• Ability to be flexible, work under pressure and meet deadlines.

• Ability to analyze and solve problems with professionalism and patience, and to exercise good judgment when making decisions.

• Ability to operate typical office equipment.

• Working knowledge of general office procedures

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel as classified.