UM LVN
: Job Details :

The Utilization Management LVN is responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision making, as it relates to the application of criteria and application of defined levels of hierarchy and composition of compliant denial notices to review medical records, authorize requested services and prepare cases for physician review based on medical necessity. The position partners with both the Pre-Service and In-Patient Utilization Management teams. Ensures to monitor and assure the appropriateness and medical necessity of care as it relates to quality, continuity and cost effectiveness. Responsibilities may include:- Reviews designated requests for referral authorizations either proactively, concurrently or retroactively. Gathering all information needed to make a determination and/or coordinate with the Medical Director as needed.- Ensure compliance with turnaround times and accuracy standards are met.- Ensure contracted providers a...LVN, Medical Director, Patient Care, Health, Management, Vocational Nurse, Healthcare