• Utilization Review LVN

    Job ID
    2019-86579
    Employment Type
    Full Time
    Department
    Utilization Review
    Hours / Pay Period
    80
    Facility
    Dignity Health Management Services Organization
    Shift
    Day
    Location
    Bakersfield
    Optional Work Location
    US-CA-Redlands
    State/Province
    CA
    Standard Hours
    Monday - Friday 8:00 - 5:00
    Work Schedule
    8 Hour
  • Overview

    The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

     

    Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options, including medical, dental and vision plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

    Responsibilities

    The utilization review LVN uses clinical judgement in providing utilization management services. The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary. The LVN assists in determining appropriateness, quality and medical necessity of referral requests using pre-established guidelines.  The position will be assigned cases for review in pre-authorization areas, skilled nursing facility review and acute inpatient concurrent review.

     

    PRINCIPLES DUTIES AND RESPONSIBILITIES

     

    • Conducts pre-authorization referral reviews, following workflow as written, document criteria to make determination or recommendation and process the referral in a timely manner.
    • Manages assigned queues on a daily basis working oldest referrals first to assure 98% compliance with ICE timeframes.
    • Follows job work aide in sequence of performing job, including checking eligibility on health plan websites. Demonstrates 100% accuracy of identification of DHMG-IE/DHPN-IE member before referral review is initiated.
    • Determines correct type of referral and utilizes correct criteria in performing review and documents appropriate sections with 95% accuracy.
    • Researches correct information and/or uses pend letter appropriately when facts are needed to reach determination.
    • Preps case thoroughly, concisely and clearly for physician review. Researches EMR, criteria, medical policy and past history of member to detail case cleanly for MD in 95% of the cases.
    • Watches for follow up and processes denials as indicated, demonstrating wording at 6th and or 8th grade level, clear sentence structure and correct identification of reasons for denial.
    • Communicates findings to physician and member in accordance with all regulatory and of DHMG-IE/DHPN-IE guidelines and documents same in 95% of cases.
    • Supports co-workers to covers needed staffing, training or special projects as assigned.
    • The LVN performs audits of medical records as requested or appropriate.
    • Recommends and coordinates interventions to facilitate high quality, cost-effective care, monitoring treatment, progress and outcomes of patients.
    • The LVN performs Inter-Rater Reliability audits as directed by the UM Supervisor or UM Manager.
    • The LVN scores over 95% on personal Inter-Rater audits as reviewed by peers.
    • The LVN performs audits of medical records as requested or appropriate.
    • The LVN assists in the refinement/improvement of the utilization management program through participating in continuous process improvement endeavors.
    • The LVN uses professional and collaborative behavior while interacting with all customers.
    • The LVN demonstrates the ability to work within their scope of practice as defined by the Department in all stages of work.
    • The LVN responds promptly and with courtesy to inquiry from claims, other hospitals, other departments seeking assistance, member services, management, physicians and others by either resolving the situation or referring it appropriately. Documentation is completed for all issues to create a record.
    • The LVN requests assistance when needed to ensure that the appropriate actions are taken in each situation.
    • The LVN performs special projects or other assignments as requested by the Supervisor, Manager or Director.
    • Dignity - Respecting the inherent value and worth of each person. Justice - Advocating for social change and acting in ways that promote respect for all persons and demonstrate compassion for our sisters and brothers who are powerless. Stewardship - Cultivating the resources entrusted to us to promote healing and wholeness. Collaboration - Working together with people who support common values and vision to achieve shared goals. Excellence - Exceeding expectations through teamwork and innovation.
    • Consistently and positively communicates and collaborates with colleagues, supervisor, and customers (internal and external). Communicates collaboratively in situations involving conflict so the conflict de-escalates and is resolved
    • Efficiently and independently plans time to accomplish job duties within departmental standards. Employee is punctual, meets deadlines, initiates and follows through on tasks, and needs little supervision.
    • Meets or exceeds behavioral standards to work effectively with internal and external customers. Is professional and courteous in all situations. Anticipates needs of others and works to fulfill them. Listens respectfully and carefully, demonstrating flexibility in working with others.
    • Demonstrates sensitivity to people of different cultures and works effectively with them.
    • All other duties as assigned.

    Qualifications

    1. EXPERIENCE: Minimum 3 years UM experience. 5 years’ clinical experience as a LVN in acute, ambulatory care, home health or SNF.
    2. EDUCATION AND TRAINING: Knowledge of health plans. Medical specialty procedures and diagnoses.  Strong knowledge nursing requirements in a clinical setting. Knowledge of utilization management programs as related to pre-set protocols and criteria.
    3. LICENSURE: California LVN license. 

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