Texas – Remote LVN LPN Utilization Management Nurse

Job Overview

  • Clinical License LPN, LVN
  • State(s) TX

Clinical

Compassion. It’s the starting point for health care providers like you and it’s what drives us every day as we put our exceptional skills together with a real feeling of caring for others. This is a place where your impact goes beyond providing care one patient at a time. Because here, every day, you’re also providing leadership and contributing in ways that can affect millions for years to come. Ready for a new path? Learn more, and start doing your life’s best work.SM

 

Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work. (sm)

 

WellMed provides concierge – level medical care and service for seniors, delivered by physicians and clinic stat that understands and care about the patient’s health. WellMed’s proactive approach focuses on prevention and the complete coordination of care for patients. WellMed is now part of the Optum division under the greater UnitedHealth Group umbrella.

 

This position manages the pre-certification process for health care services requiring application of criteria and medical necessity prior to services being rendered for eligible members.  The Utilization Management LVN acts as a liaison in evaluating incoming requests for medical services with communication to providers regarding specific information required for physician review, explanation of patient’s benefits, and ensuring that medical care is not delayed by UM process.  Timely and reliable preparation of cases for physician review is essential to ensure work flow results in accurate and consistent application of criteria.

 

If you are located within a commutable distance of a WellMed office and have telecommute experience, you will have the flexibility to telecommute* as you take on some tough challenges.

 

Primary Responsibilities:

  • Monitors health care services in the determination of level of review required by service type as indicated by financial status or complexity
  • Collects benefit, criteria and clinical information to perform clinical review decisions
  • Gathers additional information and research requests for cases requiring presentation to medical director
  • Generates referral entries accurately identifying the covered services authorized including ICD-9 coding, service groups and appropriate medical terminology in text
  • Communicates to providers and patients regarding outcome of review
  • Expedites requests that are required within 72 hours or have a high acuity of healthcare required
  • Shows appropriate judgment in forwarding complex cases or new technology review to UM Medical director without delaying authorization request
  • Verifies eligibility with accurate identification of patient benefit according to specific health plan enrollee
  • Notifies patient and providers of referral determination in a professional manner with identification of critical needs that a patient may convey during notification
  • Assists providers in referral processing related to urgent care required due to medical necessity of clinical data
  • Partners with nurse reviewer coordinator to ensure timely faxing of referrals within mandated time frames with reliable documentation of notification
  • Case preparation of intake form completed referrals in appropriate manner for auditing
  • Serves as liaison between UM Department and Medical Groups and assist with benefit questions
  • Collects and relays clinical information using approved medical terminology and acronyms
  • Follows through with problem identification / resolution originated by supervisory staff regarding physician determinations
  • Develops strong clinical skills in gathering information and entering into a case file for UR review

 

Quality

 

  • Works independently without supervision in consistently meeting performance requirements of the UM program
  • Communicates compliance information accurately to all parties
  • Knowledge of resources that provide information on all managed care contracts, protocols, service groups, status and type codes
  • Demonstrates consistent turn around times with pre-certification processing and notification
  • Takes ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction and seek ways to improve job   efficiency and makes suggestions to the appropriate manager
  • Assures that member’s care is maintained at an achievable level of quality in a cost efficient manner by using the WMMI provider network
  • Ensures that pertinent information relating to the healthcare of patients is collected and readily available to the UM Committee for education and corrective action if indicated
  • Attends educational offerings to keep abreast of change and comply with licensing requirements

 

Customer Service

 

  • Performs all duties to customers in a prompt, pleasant, professional and responsible manner regardless of the stressful nature of the situation and always identifies self by name and title
  • Maintains flexibility and enthusiasm and assist others when a staffing problem occurs including assisting other departments with phone coverage and word processing
  • Respects customer and organizational confidentiality policy
  • Works closely with medical director, providers and patients in the review of health care services with the development of decisions or actions to resolve problematic issues
  • Preserves a positive working relationship and cooperates well with all departments
  • Serves as liaison between UM Department, patients and providers

 

Compliance

 

  • Demonstrates consistent turnaround time as stated in WMMI UM Program
  • Coordinates quarterly audits with health plan in presenting data for review and intermediates with auditor on behalf of physician decisions
  • Ensures compliance of the UM Program specifically with the Denial Process
  • Forwards timely denial decisions to the denial area with a shared responsibility of notification to patient and provider for understanding of decision and benefit criteria
  • Maintains basic knowledge of UM processes to ensure compliance and oversight of process of physician groups and Health Services Coordinators
  • Keeps abreast of all new or revised WMMI policies and procedures when posted or distributed
  • Attends educational offerings to keep abreast of change and comply with licensing requirements

 

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • High school diploma or GED
  • Current LVN license in state of Texas
  • Experience in physician office as clinical LVN
  • Proficient in PC software computer skills
  • Sound knowledge of managed care, medical terminology, referral process, and ICD-9 coding
  • Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive VoiceResponse (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained
  • You will be asked to perform this role in an office setting or other company location, however, may be required to work from home temporarily due to space limitations

 

Preferred Qualifications:

  • 2+ years of experience in managed care or referral management position
  • 4+ years of clinical experience in primary care physician office or hospital setting
  • Excellent verbal and written skills
  • Ability to interact productively with individuals and with multidisciplinary teams
  • Independent problem identification and resolution of patient issues originated by unfavorable decisions regarding medical care in support of physician reviewer decision by education of benefits and criteria standards
  • Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills
  • Previous Prior Authorization experience
  • InterQual or Milliman Knowledge / experience
  • ICD-10, CPT coding knowledge / experience
  • Utilization Review / Management experience
  • Telephonic and/or telecommute experience

 

 

 

Careers with WellMed. Our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors. We’re impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We’ve joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life’s best work.(sm)

 

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

 

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

 

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