JOB TITLE:

UTILIZATION MANAGEMENT LVN (CALIFORNIA LICENSE)

SALARY:

$35.56

Role Summary:

The Utilization Management LVN or LPN is responsible for the review and audit of authorization requests to ensure services that are authorized meet standard medical guidelines. Ensuring the right care is done in the right place at the right time is a critical aspect of this role. This role is also responsible for supporting the organization’s utilization management program through close auditing of participants’ charts and authorization requests. This role requires strong working knowledge of UM regulatory and documentation standards. The Utilization Management LVN or LPN will work in a cross-team capacity to support the broader WelbeHealth mission.

• Duties and Responsibilities:

• Chart audits of consult summaries, imaging results, procedure summaries, and more to determine if additional follow up services are requested

• Management of departmental clinical inboxes, email inboxes, and fax queues to ensure appropriate handling of documents and authorization requests.

• Works closely with coordinators, nurses, Medical Records, Provider Networking, and center-based clinical staff to promote efficient and effective communication and document routing between multiple sources and systems.

• Identifies, documents, and corrects inconsistencies and gaps in participants charts with authorizations in the system

• Reviews prior authorization requests for medical necessity and alignment with participants’ care plans. This can include routine office visits, procedures, DME, and more.

• Collaborates with providers, clinical staff, and others to timely resolve any authorization gaps identified

• Consistently meets operational performance requirements as detailed by data and company reporting.

• Maintains accurate documentation to ensure company compliance with authorization review and participants’ services

• Understands and follows routing protocol and workflows to ensure proper and timely delivery of clinical documents to applicable departments and individuals.

• Strong connection to Welbe’s value of Shared Intention through teamwork and collaboration.

• Completes all required documentation in a timely and accurate manner.

• Protects privacy and maintain confidentiality of all company procedures and information about team members, participants, and families.

• Follows WelbeHealth policies and procedures and participate in any required Quality Improvement activities, staff training and meetings.

• Communicates regularly with direct supervisor regarding findings

• Completes all mandatory training and education timely.

• Completes all mandatory health screenings/requirements timely.

• Exercises flexibility in performing assignments as business needs evolve.

• Other duties as assigned.

• Qualifications and Requirements:

Education/Training/Certifications:

• Diploma from an accredited nursing school required. ASN or BSN preferred.

• Licensed Vocational (or Practical) Nurse or LPN in good standing.

• Ability to obtain CA state license for LVN

• Minimum of one year of chart auditing or review experience

Skills and Experience:

• Minimum of 2 years relevant administrative and clinical work

• Knowledge of and experience working in Athena Electronic Health Record is preferred

• Knowledgeable in areas of Medicare and Medicaid regulations

• Excellent interpersonal communication, problem-solving and conflict resolution skills

• Ability to follow directions from supervisor and communicate needs effectively.

• Excellent organizational and communication skills.

• Ability to work independently with minimal supervision.

• Demonstrated ability to prioritize work in a queue and manage volume timely

• Experience and competency working with people from diverse backgrounds and cultures.

• Commitment to unlocking the full potential of our most vulnerable seniors.

Medical Clearance:

Required that Team Members must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact. Additional screening may be required as determined by the Medical Director and Human Resources Director in order to protect participants and the community from communicable disease outbreaks (e.g., COVID-19).

Regulatory Requirement ongoing:

Must not be on any exclusion or debarment from participation in Federal Health Care Programs at any time and must remain in good standing with government regulators such as the OIG, (Office of the Inspector General), SAM, (System for Award Management), CMS (Centers for Medicare and Medicaid Services), etc.

• Physical Demands and Working Conditions:

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. In compliance with ADA requirements, reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

• Work Environment: Team Member must be able to work effectively within an interdisciplinary team model, interfacing and collaborating with a wide range of clinical and social services disciplines who work together to manage the PACE participants' care. The work setting is in an Adult Day Health Center, primary care clinic, other healthcare settings like hospitals, emergency departments and participant home environment with moderate noise levels and controlled temperatures.

• Physical Requirements - Requires corrected vision and hearing to normal range. Must be able to communicate with all staff, vendors, and clients. Requires manual and finger dexterity and eye-hand coordination; the ability to use department equipment.

• Visual, Hearing and Communication Requirements - Requires corrected vision and hearing to normal range, with or without reasonable accommodation. Ability to communicate by way of the telephone with participants, customers, vendors, and staff.

• Pressure Factor - Requires working under stressful conditions. Working conditions may be noisy and crowded and fluctuating indoor temperatures. Moderate pressure to meet scheduled deadlines. Potential for exposure to verbal aggression by Participants and/or their family members who may suffer from comorbidities such as dementia or mental health challenges.

• Environmental Conditions - May be exposed to a risk of bodily injury through contact with moving instrumentation, toxic substances, medicinal preparations, bodily fluids, communicable diseases and any other conditions common in a healthcare environment. May be subjected to unpleasant odors.