Licensed Vocational Nurse LVN LPN PA Utilization Management Nurse Texas
Company: Unitedhealth Group
Location: El Paso
Posted on: August 7, 2022
Job Description:
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 lifes 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 patients health. WellMeds
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 patients 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 the TX area, 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 solid clinical skills in gathering information and
entering into a case file for UR reviewQuality
- 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 members 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 requirementsCustomer 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
providersCompliance
- 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 requirementsYoull 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
- Sound knowledge of managed care, medical terminology, referral
process, and ICD-9 coding
- Proficient in PC software computer skills
- Full COVID-19 vaccination is an essential job function of this
role. Candidates located in states that mandate COVID-19 booster
doses must also comply with those state requirements. UnitedHealth
Group will adhere to all federal, state and local regulations as
well as all client requirements and will obtain necessary proof of
vaccination, and boosters when applicable, prior to employment to
ensure compliance. Candidates must be able to perform all essential
job functions with or without reasonable accommodationPreferred
Qualifications:
- 4+ years of clinical experience in primary care physician
office or hospital setting
- 2+ years of experience in managed care or referral management
position
- Prior Authorization experience
- InterQual or Milliman Knowledge / experience
- ICD-10, CPT coding knowledge / experience
- Utilization Review / Management experience
- Telephonic and/or telecommute experience
- Bilingual English/Spanish
- 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
- Excellent verbal and written skills
- Possess planning, organizing, conflict resolution, negotiating,
and essential interpersonal skillsTo protect the health and safety
of our workforce, patients and communities we serve, UnitedHealth
Group and its affiliate companies require all employees to disclose
COVID-19 vaccination status prior to beginning employment. In
addition, some roles and locations require full COVID-19
vaccination, including boosters, as an essential job function.
UnitedHealth Group adheres to all federal, state and local COVID-19
vaccination regulations as well as all client COVID-19 vaccination
requirements and will obtain the necessary information from
candidates prior to employment to ensure compliance. Candidates
must be able to perform all essential job functions with or without
reasonable accommodation. Failure to meet the vaccination
requirement may result in rescission of an employment offer or
termination of employmentCareers 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)WellMed was
founded in 1990 with a vision of being a physician-led company that
could change the face of healthcare delivery for seniors. Through
the WellMed Care Model, we specialize in helping our patients stay
healthy by providing the care they need from doctors who care about
them. We partner with multiple Medicare Advantage health plans in
Texas and Florida and look forward to continuing growth.*All
Telecommuters will be required to adhere to UnitedHealth Groups
Telecommuter PolicyDiversity creates a healthier atmosphere:
OptumCare is an Equal Employment Opportunity/Affirmative Action
employers 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.OptumCare is a drug-free workplace. Candidates are required to
pass a drug test before beginning employment.by Jobble
Keywords: Unitedhealth Group, El Paso , Licensed Vocational Nurse LVN LPN PA Utilization Management Nurse Texas, Executive , El Paso, Texas
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