Utilization Management Review Nurse LVN

Utilization Management Review Nurse LVN

Salary Range : $74,557 - $111,835

The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status : Non-Exempt

Department : Health Services

Reports To : Health Services Management

Employee Unit : Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521

GENERAL DESCRIPTION OF POSITION

Under the guidance and direction of the UM department RN Manager or Director, the Utilization Management Review Nurse (LVN) performs prospective and retrospective clinical review for inpatient and outpatient authorization requests in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and applicable business requirements. Following regulatory or evidence-based guidelines, assesses for medical necessity of services and / or benefit coverage which result in approved determination for services or the need to collaborate with Medical Directors for potential denial considerations.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

• Conduct clinical review to ensure effective and appropriate utilization of benefits and services for prospective, concurrent and retrospective / claims review organization determination authorization requests within regulatory turnaround requirements for all SCFHP lines of business.
• Process authorization reviews by applying the appropriate clinical criteria / guidelines, policies and procedures.
• Draft and process timely notification of action (NOA) letters for authorization determinations to providers and to members, in member specific language preferences as identified within member demographic information.
• Coordinate referrals to appropriate departments or programs for member identified continuity of care needs, such as Case Management, Behavioral Health, Managed Long Term Services and Supports (MLTSS), community resources, Pharmacy and Quality.
• Maintain adherence with CMS (Medicare) and DHCS (Medi-Cal) regulatory requirements.
• Facilitate appropriate processing of Letters of Agreement with non-contracted Providers for approved medically necessary services.
• Perform other duties as required or assigned.

REQUIREMENTS - Required (R) Desired (D)

The requirements listed below are representative of the knowledge, skill, and / or ability required or desired.

WORKING CONDITIONS

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation :

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.

EOE

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