Description
General Summary of Position
The LPN Case Manager, Clinical Authorization is responsible for coordinating and facilitating the review, authorization, and management of medical services to ensure appropriate utilization of healthcare resources. This position involves reviewing clinical documentation, applying medical necessity criteria, and collaborating with physicians, providers, and health plan members to support quality patient care within benefit and policy guidelines.
*1-2 years case management, utilization review, or managed care required
*Please Note: This role requires you to be on-site in Washington, DC, four days per week, with one remote workday each week. Additional flex-time may be allocated in the future*
Primary Duties and Responsibilities
Assists in the identification of potential Case Management candidates through clinical review, selected diagnoses, etc. and makes appropriate referrals.Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy.Identifies and reports potential coordination of benefits, subrogation, third party liability, workers compensation cases, etc. Identifies quality, risk, or utilization issues to appropriate MedStar personnel.Initiates contact with providers to obtain clinical information to facilitate care or pending pre-certification requests. Interacts with assigned disease management populations of limited volume. Interaction is designed to improve patient access to care, and education regarding the disease and support services.Maintains current knowledge of MedStar Family Choice benefits and enrollment issues in order to accurately coordinate services.Maintains expertise in general benefit management and serves as a resource for MedStar Family Choice members, physicians, and staff for benefit interpretation and coordination.Maintains timely and accurate documentation in the IS System per Case Management policy.Participates in meetings, work groups, etc. as assigned.Processes pre-authorizations for medical necessity, LOC, covered benefits, and participation of the provider at the discretion of the guidelines and Medical Reviewer.Sends reviews to Medical Reviewer as appropriate. Coordinates review decisions and notifications, per policy.CUSTOM.PRIMARY.DUTIES.RESPONSIBILITIES.ADDENDUM
Minimum Qualifications
Education
- Valid LPN License in the District of Columbia. required
Experience
- 1-2 years Utilization review experience required and
- 3-4 years Diverse clinical experience required
Licenses and Certifications
- LPN - Licensed Practical Nurse - State Licensure Valid LPN license in the State of Maryland or District of Columbia. Upon Hire required
Knowledge, Skills, and Abilities
- Knowledge of current trends in healthcare delivery and utilization review criteria.
- Ability to use computer to enter and retrieve data.
- Ability to create, edit and analyze (Word, Excel and PowerPoint) preferred
This position has a hiring range of $60,632 - $107,494
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