Remote Medical Management Nurse 1 (LPN/LVN) – Texas

Position summary:

Reporting to the Medical Management Director. The title of this role is Medical Management Nurse. The role required a current and unrestricted Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license, with TX licensure required within six (6) months of employment. This is a part time role requiring coverage for each Saturday, Sunday and holidays. Hours of operation are 9AM CST to 3PM CST. Additional coverage to meet department needs may be scheduled as mutually agreed upon. The nurse shall facilitate the timely processing of authorization requests, after verification of eligibility and make certain that clinical information is provided to support a timely review determination. This position requires working knowledge of UM Criteria, including Medicare National Coverage Determinations (NCD) and Local Coverage Determination (LCD) criteria and guidelines, Health Plan criteria, Milliman Care Guidelines (MCG), ICD.9/10, CPT Coding and Medical Terminology.

Essential functions:

● Following established departmental processes and guidelines, the MM Nurse 1 reviewer reviews authorizations and applies specific medical necessity guidelines for approval of requests.

● Review on a concurrent basis, ongoing care at the acute, skilled, home care levels to determine appropriateness of continued care at the current level of care

● Make certain that all referrals are processed in a timely manner and support compliance with appropriate turnaround timeframes

● Responsible for checking the referral for completeness of supporting clinical information and obtaining missing medical records or clinical information as needed in support of a thorough review and appropriate review outcome.

● Responsible for meeting accuracy standards for appropriate authorizations of referrals.

● Utilize and apply medical necessity criteria based on the organization’s established hierarchy

● When unable to approve the authorization, prepares information to be sent to the UM Medical leader for further review and determination.

● Support compliance with applicable laws, regulations, procedures, and policies.

Experience:

● Minimum of two (2) years of experience as a nurse, in a hospital, skilled facility, doctor’s office or managed healthcare delivery organization

● Minimum of one (1) year of experience in UM in a medical group, health plan or other managed care organization

Qualifications:

● Current and unrestricted Registered Nurse or Licensed Vocational Nurse license. Evidence of a valid TX license required six months from hire date.

● Current knowledge of State and CMS regulations

● Knowledge of UM principles and standards

● Excellent verbal and written communication skills.

● Computer literate and comfortable with electronic documentation systems

This position, along with team members within assigned departments and across the organization, fosters an engaging and professional environment committed to respect, inclusivity, continuous improvement, and teamwork.

The position works within policies and procedures, related to the department and organization, and supports efforts needed for organizational growth, proposal developments, fiscal management, and monitoring, reporting and analysis, and support compliance with local, state, and federal regulations as well as regulatory, controlling, and licensing agencies.

TECQ Partners provides equal access to and opportunity in its organization and employment, without regard to race, color, creed, religion, national origin, gender, age, marital status, disability, public assistance status, veteran status, sexual orientation, gender identity, or gender expression.

Pay: $36.00 – $40.00 per hour

Expected hours: 12.0 per week

Work Location: Remote