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LPN, Utilization Management

Company: DaVita Medical Group
Location: Albuquerque
Posted on: June 15, 2019

Job Description:

LPN, Utilization Management Full Time Licensed Practical Nurse, Utilization Management Opportunity in Care Management, Roma LocationOverview of Position:Responsible for timely, accurate medical review, determining if requests for services to be provided to DaVita Medical Group patients meet criteria for coverage based upon medical policies, guidelines, and health plan criteria. Responsible for review of inpatient length of stay for compliance with medical policies, guidelines, and health plan criteria. Based on criteria may refer cases to Medical Director Care Management for further review. Ensures compliance to contractual and service standards as identified by relevant health insurance plans and DaVita Medical Group. This is performed under the direct supervision of the Medical Director, Care Management. Adheres to policies, procedures and regulations to ensure compliance and patient safety. Participation in Compliance and other important training is a condition of employment.Essential Functions: Provides timely, accurate review of precertification and prior authorization requests, for compliance with applicable medical policies and health plan benefits. Provides concurrent medical review of inpatient length of stays to ensure compliance with applicable medical policies and health plan benefits. Responsible for providing both outpatient and inpatient medical management review as needed, to ensure that patient healthcare requirements and organizational goals are met in a reasonable and medically appropriate manner. Ensure communication regarding medical reviews are provided to relevant patients and Providers in a timely manner, and in compliance with contractual agreements. Ensures compliance with HIPAA and other applicable company policies and procedures as well as regulatory requirements. Identify and address opportunities for quality improvement in all aspects of serving our customers. Assist in planning and implementation of systems changes and procedures to achieve overall organizational objectives. Maintain effective communication with management regarding development within areas of assigned responsibilities and performs special projects as required. Performs other duties as assigned.Education:Required- High School diploma or GED equivalent and graduation from an accredited practical nursing program.Preferred- Associate's degree in Nursing; Certified Case Manager.Experience:Required- Three (3) years of previous job related experience in a healthcare environment.Preferred- Two (2) years' experience providing case management and/or utilization review functions within health plan or integrated system.Required licensure:Required-Valid, unrestricted, NM LPN License or valid multi-state compact license.Must be 21 years or older and have a valid NM State Driver's license.Preferred-Utilization Review or Case Management Certificate.Knowledge/Skills/Abilities:PC proficient; ability to communicate and interact professionally with co-workers, management patients, and Providers; ability to counsel and/or consult; knowledge of medical terminology and working knowledge of HMO's, PPO's, Medicare, Medicaid, and insurance plans; knowledge of CPT4/ICD 9 & 10/HCPCS codes.DaVita Medical Group is one of the nation's leading medical groups and is a national medical group with operations in New Mexico, Nevada, Colorado, Florida, California and Washington. It is an exciting time to join DaVita Medical Group NM as we blaze new trails in coordinated care, setting the new standard in New Mexico for compassionate, cost-effective, high quality healthcare.If you're looking to make a difference with a large, financially stable, well-recognized medical group, DaVita Medical Group may be the employer for you.DaVita Medical Group is an equal opportunity/affirmative action employer. As such, DaVita Medical Group makes hiring decisions solely on the basis of qualifications and experience, and without regard to age, race, color, religion, sex, gender identity, sexual orientation, national origin, disability or protected veteran status.We maintain a drug-free workplace and perform pre-employment substance abuse testing and background verification checks.DaVita Medical Group will consider qualified applicants who have criminal histories in a manner consistent with the law.

Keywords: DaVita Medical Group, Albuquerque , LPN, Utilization Management, Executive , Albuquerque, New Mexico

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