Utilization Management LVN Nurse

$27 - $40/Yr

Tenet Healthcare - Frisco, TX

Frisco, TX

Hospitals

About the position

The Utilization Management (UM) Nurse ensures quality of patient care, effective utilization of available health services, review of admissions for medical necessity, necessity of continued stay in the inpatient setting, and medical necessity for outpatient services. Ensures members have a safe discharge plan in place prior to discharge from the inpatient setting.

Responsibilities

• Responsible for providing timely referral determination by accurate usage of the Milliman Care Guidelines.
• Identification of referrals to the medical director for review.
• Appropriate letter language (i.e. - denials).
• Appropriate selection of the in or out of network providers.
• Proper identification of eligibility and health plan benefits.
• Maintain compliance in turnaround time requirements.
• Work closely with supervisor/lead to address issues and delays that can cause a failure to meet or maintain compliance.
• Meets or exceeds production and quality metrics.
• Work directly with the provider(s) and Medical Director to facilitate quality service to the member and provider.
• Identifies and refers members to the appropriate healthcare program (e.g. case management, disease management).
• Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
• Collaborates, educates, and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria.
• All other job-related duties as it relates to the job function or as delegated by management.

Requirements

• Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.
• Proficient with Microsoft Word, Outlook, and Excel.
• Medical Terminology preferred.
• High School Diploma or GED.
• 3-5 years of acute care experience.
• 2 years Health Plan Utilization Review or equivalent.
• 2 years managed care experience in UM/CM Department, preferred.
• ICD-10 and CPT coding experience a plus.
• Experience working in a health plan medical management documentation system a plus.
• Experience in EZ-CAP preferred (California only).

Benefits

• Medical, dental, vision, disability, and life insurance.
• Paid time off (vacation & sick leave) - min of 12 days per year, accrue at a rate of approximately 1.84 hours per 40 hours worked.
• 401k with up to 6% employer match.
• 10 paid holidays per year.
• Health savings accounts, healthcare & dependent flexible spending accounts.
• Employee Assistance program, Employee discount program.
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
• For Colorado employees, Conifer offers paid leave in accordance with Colorado's Healthy Families and Workplaces Act.