UTIL. REVIEW NURSE LPN - CASE MANAGEMENT
Status: Full Time
Shift: M - F 7a-3:30p
Exempt: No
Other information:
1. Previous Experience Requireda. Five to ten years of clinical nursing experience of which at least five years were in direct patient care areas.b. Utilization Review experience preferred.2. Specialized or Technical Education Requirementsa. Licensed Practical Nurse currently licensed to practice in the State of Louisiana.b. Knowledge of Prospective Payment System, DRG’s, and Peer Review Organizations preferred.c. Surgery/ICU training preferred.d. Knowledge of ICD-9-CM and CPT coding preferred.3. Manual or Physical Skillsa. Basic Computer skills preferred.4. Physical Effort RequiredStrength: SedentaryPush: occasionallyPull: occasionallyCarry: occasionallyLift: occasionallySit: frequentlyStand: frequentlyWalk: frequently
Responsibilities:
1. Applies medical necessity, severity of illness/intensity of service criteria for patients seeking inpatient admission or continued stay.2. Ensures consistent data capture to identify trends/problems related to delivery of care delays and potentially avoidable days.3. Performs admission review, completes necessary documentation for Medicaid and third party payer precertification.4. Performs continued stay review (if assigned) as needed for LOS extension on Medicaid and third-party payer patients.5. Communicates clinical review information to all third party utilization review companies as per established policies and procedures to ensure continued benefit coverage for patients.6. Maintains and documents third-party payer’s authorizations, contacts, and transactions for individual patients.7. Collaborates daily with the RN Care Managers and other team members to support the assessment of continued need for acute care hospitalization.8. Studies information available to remain abreast of reimbursement modalities, community resources, review systems, and clinical and legal issues that affect patients and providers of care.9. Performs needed concurrent and retro reviews daily and obtains authorizations.10. Performs retro reviews on patients that change from private pay to Medicaid or who run out of Medicare days within the allotted time.11. Manages Medicaid denials by initiating the appeals process through interaction with the RN Care Managers, obtaining appropriate medical record information, scheduling the MD-to MD conferences once the MD has selected a date/time, and having the appropriate information sent in preparation for the appeals conference. Enters relevant information into account notes and onto denial log.12. Facilitates the insurance denial appeals process by entering appropriate documentation into patient’s account notes, onto denial logs and forwarding UR information to the PFS Nurse Auditor.13. Reviews all denial notifications daily and facilitates peer-to-peer reviews, writes appeals and notifies Utilization and Denials Manager as needed for resolutions and guidance.14. Manages Work Queues as assigned for Retro reviews, claim edits, and any other assigned.15. Maintains Medicaid denial and peer-to-peer logs on J: drive.16. Fosters positive internal and external customer relations.17. Provides orientation and mentoring to new staff.18. Continually evaluates case management services and client outcomes.19. Follows North Oaks Health System’s Compliance Programs and federal and state regulatory guidelines.20. Other duties as deemed necessary and appropriate.