LPN, Utilization Review Job at Triton Health Systems in Birmingham

LPN, Utilization Review

Location: Birmingham, AL

Work Schedule: Hybrid schedule with regular onsite presence at the VIVA HEALTH corporate office and some work-from-home opportunities.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan, receiving a 5 out of 5 Star rating - the highest rating a Medicare Advantage Plan can achieve and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

Benefits

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Healthcare Reimbursement Account
• Paid Parental Leave
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Employee Assistance Program

See more about the benefits of working at Viva Health - https://www.vivahealth.com/careers/benefits

Job Description

The LPN, Utilization Review is responsible for answering phone calls and responding to faxed requests from providers for services that require prior authorization. This position reviews requests for medical necessity using evidenced-based criteria or internal guidelines while maintaining compliance with departmental and federal regulations.

Key Responsibilities

• Responsible for using evidenced-based criteria and/or VIVA HEALTH internally developed criteria to review provider requests for prior authorization of outpatient and inpatient services for Commercial and Medicare product lines.
• Coordinate authorizations including specialist referrals, outpatient therapies, surgeries, durable medical equipment (DME), and pharmacy services both internally and externally in accordance with departmental guidelines and federal regulations.
• Ensure services authorized are covered benefits and medically necessary citing criteria, certificate of coverage, or evidence of coverage used to make determinations.
• Forward potential denials to the Medical Director or designee as well as any other services requiring administrative review to proper designee.
• Regularly review pending authorizations to ensure timely completion or request extension for final decision date if needed.

REQUIRED:

• High School Diploma or GED
• 1 – 3 years’ experience as an LPN in a hospital setting, private physician or ancillary vendor’s office
• Current LPN License in good standing with the State of Alabama Board of Nursing
• Licensed Practical Nurse Certification
• Ability to research, read and interpret health plan or governmental contracts, and medical policy guidelines
• Demonstrate excellent customer service skills through written and verbal communication
• Ability to meet strict deadlines and turnaround times
• Basic computer and data entry skills

PREFERRED:

• Utilization review or precertification experience utilizing InterQual or Milliman guidelines
• Relevant customer service or call center experience
• Telephone queue experience