Utilization Management LVN

Job Description

Job Description

Your Passion

If you are as passionate about helping those in need as you are about growing your career, we invite you to consider joining our team of professionals at Maren Medical Group. At Maren, your passion for helping others isn’t just welcomed – it’s nurtured, celebrated, and promoted, allowing you to grow while making a meaningful difference. Maren is a community focused medical group that is patient centric. At Maren, you will work with colleagues and providers who provide exceptional care, and whose commitment and dedication goes beyond just a job; it’s a calling that drives us forward every day.

Job Overview

The LVN Utilization Management Nurse (UM Nurse) will provide routine review of authorization requests from all lines of business using respective national / state, health plan, and nationally recognized guidelines. Responsible for reviewing proposed hospitalization, home care, and inpatient / outpatient treatment plans for medical necessity and efficiency with coverage guidelines. The UM Nurse determines the medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.

Essential Functions

• Research and assist with development of treatment / care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type.
• Assist with Initiation / implementation of timely individualized care plans (ICP) based on health risk assessment (HRA) completion, participation in and documentation of interdisciplinary meetings (ICT), assisting in transitions of care across all ages.
• Determines appropriateness of referral for CM services, mental health, and social services.
• Provides Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD).
• Conducts member care review with medical groups or individual providers for continuity of care, out of area / out of network and investigational / experimental cases.
• Assist in managing member treatment in order to meet recommended length of stay. Ensures DC planning at levels of care appropriate for the members needs and acuity.
• Assessment : Gather data on members’ health behaviors, cultural influences and clients belief / value system. Evaluates all information related to current / proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriers.
• Research opportunities for improvement in assessment methodology and actively promotes continuous improvement. Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and BSC.
• Determines realistic goals and objectives and provides appropriate alternatives. Actively solicits client’s involvement.
• Planning : Assist in designing appropriate and fiscally responsible care plans with targeted interventions that enhance quality, access, and cost-effective outcomes. Adjusts plans or creates contingency plans as necessary.
• Gather data and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Assist in initiating and implementing appropriate modifications in plan of care to adapt to changes occurring over time and through various settings.
• Assist in developing appropriate and fiscally responsible care plans with targeted interventions that enhance quality, access, and cost-effective outcomes.
• Recognizes need for contingency plans throughout the healthcare process.
• Assist in developing and implementing the plan of care based on accurate assessment of the member and current of proposed treatment.

Minimum Qualifications

Company Description

Maren Medical Group, is a healthcare organization dedicated to serving patients with affordable and compassionate patient care

Company Description

Maren Medical Group, is a healthcare organization dedicated to serving patients with affordable and compassionate patient care