PURPOSE OF POSITION:
The primary purpose of the UM Utilization Management LPN process is to perform assigned duties in an efficient, cost effective manner, in accordance with the established policies, procedures and directed to assure that treatment requests of the Utilization Management Department/Case Management Department are handled properly. Some responsibilities may be shared with other personnel. The UM LPN works under the RN to provide efficient quality services at all times. The UM LPN will accomplish this goal by following all of the established policies and procedures to complete all assigned duties.
RESPONSIBILITIES & EXPECTATIONS:
- Manages assigned claims through to resolution.
- Follow and adhere to all established BWC MCO PRG, Official Disability Guidelines (ODG) and/or apply written, scientific, evidence based criteria to requests for medical treatment and/or supplies.
- UM LPN staff has access to the Medical Director or other physician reviewers for assistance in applying the guidelines and/or with interpretation of the guidelines as needed.
- When applicable criteria cannot be found to assist in the decision, the case will be staffed with and/or referred to the RN, Medical Director or other physician reviewer.
- The Medical Director or physician reviewer may use medical judgment and supersede or override the guidelines.
- Utilizes and documents utilization of appropriate criteria set in making appropriate approvals/denials. Collaborates with clinician when necessary.
- Utilize the Nursing Process to obtain adequate and accurate information for treatment requests.
- Accurately completes documentation of the treatment authorization process in the internal claims management system.
- Accurately check claim and provider status when necessary.
- Consistently communicate to providers and employers for clarification and/or with the outcome of the C-9 or ECP TX treatment request.
- Adhere to notification guidelines related to treatment requests.
- Adhere to BWC MCO PRG turnaround times for designated tasks.
- Answer incoming telephone calls within three rings. Screen and direct calls to the appropriate person if indicated.
- Use good judgment in referring inquires to other office personnel, supervisor, Director, and Medical Director or other physician reviewer.
- Consistently demonstrate ability to multi-task and prioritize work in accordance with established policies/procedures and necessity.
- Process Improvement: Continuously reviews, recommends and implements improvement steps, as needed or directed.
- Seeks supervisory guidance/approval as appropriate.
- Portrays professional image: follows dress code; communicates with internal and external customers in a professional manner, including appropriate verbal and written grammar.
- Promotes and demonstrates professional standards to enhance the development of the department.
- Practices ethical conduct.
- Meets acceptable attendance and punctuality expectations (excluding FMLA)
The above statements reflect the general duties considered necessary to describe the principle functions of the job as identified, and are not a detailed description of all the work requirements that may be inherent to this position.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender identity, sexual orientation or protected veteran status. AultCare is an EEO/AA Employer M/F/Disability/Vet.
AultCare/AHF will provide reasonable accommodations to employees or applicants with disabilities, as defined by the Americans with Disabilities Act, who are otherwise qualified to safely perform the essential functions of the job, with or without accommodation, unless such accommodation would constitute an undue hardship on AultCare/AHF or poses a direct threat to the health and safety of the individual or others that cannot be sufficiently mitigated by reasonable accommodation. Any applicant or employee who requires an accommodation to perform the essential functions of his or her job or to enjoy equal benefits and privileges of employment should notify the AultCare Human Resource Department and request such an accommodation.
- Education: Graduate of an approved Licensed Practical Nurse School of Nursing with a minimum of 4-5 years' experience. Type and setting of clinical experience will be considered in lieu of the minimum 4-5 years' experience. Previous Utilization Management experience preferred.
- Maintains current, unrestricted licensure in the State of Ohio to practice as a Licensed Practical Nurse.
- Experience in Microsoft Office, including Word, Excel and Outlook.
- Excellent written and verbal communication skills.
- Hours of operation, shifts as assigned. Occasional overtime, on-call, off-shifts (evenings and/or weekends) scheduled as necessary.
- Lunch and break periods must be coordinated with other staff members to maintain adequate office staffing during departmental operating hours.
- Sitting/standing/moving about intermittently during working hours.
- Subject to frequent interruptions and changes in priority of duties throughout the day.
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