Eisenhower Health
LVN-Utilization Management Specialist
Eisenhower Health, Rancho Mirage, California, United States, 92270
R0271233
Job Objective:
A brief overview of the position.
The Utilization Review Nurse LVN will use skilled intervention and clinical best practice to concurrently screen admission review and review with payors in collaboration with Case Management for utilization issues. In addition, the UR LVN will disseminate information to improve service to patients/members, their families, and all staff members. Will do UR and enter data in EPIC.
Reports to
MANAGER, CASE MANAGEMENT
Supervises
N/A
Ages of Patients
Pediatric
Adolescent
Adult
Geriatric
Blood Borne Pathogens
Minimal/No Potential
*Qualifications *
Education
Preferred: Bachelor’s degree in healthcare related field
Licensure/Certification
Required: Licensed Vocational Nurse in the State of California
*Experience *
Required: Three (3) years of LVN or Case Management experience
Essential Responsibilities
Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
Ensures appropriate authorization for commercial patients.
Serves as the first line responder to payor’s clinical questions and for approval for admission, per established process. Manages the payor line appropriately.
Ensures appropriate demographic information has been communicated and pre-certification/verification obtained.
Contacts UR Nurse when requests for reviews come in.
Completes Medical Necessity reviews, documenting in electronic medical record according to established policies and procedures
Calls, faxes or electronically transmits reviews to payors.
Ensures authorization information is being communicated to the business office, per established processes.
Keeps attending physician updated and aware of authorization status. Notifies attending physician of any change in authorization status.
Follows up with payors to obtain authorization, after discharge
Enters all appropriate authorization issues for follow-up.
Tracks any outstanding authorization issues for follow-up.
Provides notification of discharges to insurance payors.
Notifies the UR Nurse and Denials Coordinator of potential denials.
Supports the denials coordinator to manage retrospective appeals and documents according to established policy.
Coordinates physician reviews with the UR Nurse, inpatient case manager and appropriate physicians for the denials management process.
Performs other duties as assigned.
There's no better place to live, work, play, and prosper. At our award-winning medical facilities located in the Coachella Valley, you'll be part of a five-star team with other top health care professionals.
In 2024, we were honored to be named to Forbes' prestigious America's Best Employers List for the third time, a testament to our dedication to providing an exceptional work environment. Eisenhower Health is the sole employer in the Coachella Valley to receive this esteemed designation, solidifying our reputation as an outstanding place to build a career.
Our dedication to delivering high-quality, compassionate medical care is evident in our rankings. According to U.S. News & World Report, we hold the esteemed position of #1 in the Inland Empire and #12 in California among hospitals. Our Magnet recognition underscores our commitment to nursing excellence and quality patient care.
Our commitment to excellence extends beyond awards; we are the only hospital in Riverside County to have received a five-star rating three years in a row in the USA Government Rating System, a distinction awarded to just 10% of hospitals nationwide.
We take pride in fostering an inclusive environment for all. With a score of 95 out of 100, we have been designated as an "LGBTQ+ Healthcare Equality Top Performer" by the Human Rights Campaign, highlighting our dedication to providing compassionate care to all members of our community.
Our commitment to patient safety is unwavering, as demonstrated by our "A" grade in the Leapfrog Hospital Safety Grade for Spring 2023.
At Eisenhower Health, we don't just set standards; we raise them. Join our team and be part of an organization that is consistently recognized for excellence in health care and workplace satisfaction. Your career at Eisenhower Health will be marked by growth, innovation, and the opportunity to make a meaningful impact on the lives of our patients and the community we serve. Eisenhower Health is an equal opportunity employer.
Job Objective:
A brief overview of the position.
The Utilization Review Nurse LVN will use skilled intervention and clinical best practice to concurrently screen admission review and review with payors in collaboration with Case Management for utilization issues. In addition, the UR LVN will disseminate information to improve service to patients/members, their families, and all staff members. Will do UR and enter data in EPIC.
Reports to
MANAGER, CASE MANAGEMENT
Supervises
N/A
Ages of Patients
Pediatric
Adolescent
Adult
Geriatric
Blood Borne Pathogens
Minimal/No Potential
*Qualifications *
Education
Preferred: Bachelor’s degree in healthcare related field
Licensure/Certification
Required: Licensed Vocational Nurse in the State of California
*Experience *
Required: Three (3) years of LVN or Case Management experience
Essential Responsibilities
Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
Ensures appropriate authorization for commercial patients.
Serves as the first line responder to payor’s clinical questions and for approval for admission, per established process. Manages the payor line appropriately.
Ensures appropriate demographic information has been communicated and pre-certification/verification obtained.
Contacts UR Nurse when requests for reviews come in.
Completes Medical Necessity reviews, documenting in electronic medical record according to established policies and procedures
Calls, faxes or electronically transmits reviews to payors.
Ensures authorization information is being communicated to the business office, per established processes.
Keeps attending physician updated and aware of authorization status. Notifies attending physician of any change in authorization status.
Follows up with payors to obtain authorization, after discharge
Enters all appropriate authorization issues for follow-up.
Tracks any outstanding authorization issues for follow-up.
Provides notification of discharges to insurance payors.
Notifies the UR Nurse and Denials Coordinator of potential denials.
Supports the denials coordinator to manage retrospective appeals and documents according to established policy.
Coordinates physician reviews with the UR Nurse, inpatient case manager and appropriate physicians for the denials management process.
Performs other duties as assigned.
There's no better place to live, work, play, and prosper. At our award-winning medical facilities located in the Coachella Valley, you'll be part of a five-star team with other top health care professionals.
In 2024, we were honored to be named to Forbes' prestigious America's Best Employers List for the third time, a testament to our dedication to providing an exceptional work environment. Eisenhower Health is the sole employer in the Coachella Valley to receive this esteemed designation, solidifying our reputation as an outstanding place to build a career.
Our dedication to delivering high-quality, compassionate medical care is evident in our rankings. According to U.S. News & World Report, we hold the esteemed position of #1 in the Inland Empire and #12 in California among hospitals. Our Magnet recognition underscores our commitment to nursing excellence and quality patient care.
Our commitment to excellence extends beyond awards; we are the only hospital in Riverside County to have received a five-star rating three years in a row in the USA Government Rating System, a distinction awarded to just 10% of hospitals nationwide.
We take pride in fostering an inclusive environment for all. With a score of 95 out of 100, we have been designated as an "LGBTQ+ Healthcare Equality Top Performer" by the Human Rights Campaign, highlighting our dedication to providing compassionate care to all members of our community.
Our commitment to patient safety is unwavering, as demonstrated by our "A" grade in the Leapfrog Hospital Safety Grade for Spring 2023.
At Eisenhower Health, we don't just set standards; we raise them. Join our team and be part of an organization that is consistently recognized for excellence in health care and workplace satisfaction. Your career at Eisenhower Health will be marked by growth, innovation, and the opportunity to make a meaningful impact on the lives of our patients and the community we serve. Eisenhower Health is an equal opportunity employer.