Catholic Health Initiatives LPN Utilization Administrative Coordinator (Case Management) Full Time - Monday - Friday 8a-4:30p, Rotating Saturdays (P000019193) in CHATTANOOGA, Tennessee

LPN Utilization Administrative Coordinator (Case Management) Full Time - Monday - Friday 8a-4:30p, Rotating Saturdays (P000019193)

Description

JOB SUMMARY :

Under general supervision, supports the administrative requirements for Utilization Management and works collaboratively with Utilization Management/Concurrent Review Nurse, physicians, staff and other health care professionals within his/her Division. Interacts directly and indirectly with internal and external providers to review and monitor members’ utilization of health care services with the goal of maintaining high quality cost effective care. The role works collaboratively with Utilization Management staff to obtain information from clinical reviews and medical records in order to provide the appropriate communication for authorization of medical services and procedures. The Utilization Management Coordinator is an integral member of the health care team as well as the Divisional Care Management team. Collaborates with the Divisional Care Management team on system-wide quality improvement/performance improvement initiatives.

Essential Duties:

  • Initiates and ensures authorizations for all admissions.

  • Abstracts meaningful data from the medical record of identified patients.

  • Applies appropriate MCG clinical guidelines, and includes appropriate level of detail in clinical reviews to validate the appropriate level of care.

  • Ensures through the clinical review process that the medical record documentation supports the level of care ordered by the physician, and follows appropriate escalation protocols to resolve discrepancies and prevent denials.

  • Works collaboratively with the Case Management team to manage the patient’s length of stay (LOS) supported by the medical record documentation and the assigned MCG clinical guidelines.

  • Protects the confidentiality of patient information and adheres to company policies.

  • Accurately documents and processes electronic communications within identified process standards.

  • Actively participates in quality activities by communicating and coordinating with the care management team in the development of tools for optimal consumer outcomes and report findings.

  • Upon identification of possible concurrent denials, forwards information to the appropriate Utilization Management/Concurrent Review Nurse within identified process standards.

  • Reviews any service denials and gather necessary supporting documentation from chart audits and follows up according to procedures

  • Provides external notifications of discharges and external post-acute transfers.

  • Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies.

  • Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities.

  • Assists in the identification and reporting of Potential Quality of Care concerns.

  • Work as an interdisciplinary team member within Divisional Care Management departments.

  • Other duties as assigned within Population Health Care Management.

Qualifications

MINIMUM QUALIFICATIONS:

  • Licensed Practical Nurse degree.

  • Current unrestricted license, as LPN/LVN, in state of practice is required. Will consider LPN graduates if eligible for and obtain license within 3 months. Must have relevant clinical experience in hospital setting for this consideration.

  • Demonstrated experience in utilization management, facility concurrent review, discharge planning, and transfer coordination preferred..

  • Experience with MCG Indicia (formally Milliman Care Guidelines) authorization criteria preferred.

  • Must have excellent computer skills and ability to learn new systems.

  • Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills.

  • Must have strong organizational (time management) skills, strong interpersonal skills, the ability to handle multiple priorities with strong attention to detail

  • Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills. Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word.

  • Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost)

  • American Heart Association (AHA) Basic Life Support (BLS) for the Healthcare Provider certified or obtained by the end of the orientation period (approximately six (6) weeks).

  • Proof of completion of Mandatory Reporter abuse training specific to population served within three (3) months of hire.

Additional Responsibilities :

  • Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.

  • Adheres to and exhibits our core values: Reverence : Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us. Integrity : Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness. Compassion : Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community. Excellence : Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.

  • Maintains confidentiality and protects sensitive data at all times.

  • Adheres to organizational and department specific safety standards and guidelines.

  • Works collaboratively and supports efforts of team members.

  • Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community

Catholic Health Initiatives and its organizations are Equal Opportunity Employers.CBCHI

NOTICE

This position requires a criminal background check. Therefore, you may be required to provide information about your criminal history in order to be considered for this position.

Job Nursing - LPN

Primary Location TENNESSEE-CHATTANOOGA-MEMORIAL HOSPITAL

Daily Schedule Mon-Fri 8a-4:30p, Occ Sat

Scheduled Hours per 2-week Pay Period 80

Weekends Required Occasional

Req ID: 2017-R0128806