Are you looking for a rewarding career with family-friendly hours? Southwestern Health Resources CIN seeks to hire a Utilization Manager LVN like you to join the family.
Position Highlights
Work location: 1603 LBJ Freeway Farmers Branch, TX 75234
Work environment: SWHR Utilization Management
Work hours: Full Time (40 Hour) Day Shifts; Monday through Friday from 8-5P
With Opportunity to work remotely
Salary range: $22.32 - $36.08 per hour (based on relevant experience)
Please note: Southwestern Health Resources Clinically Integrated Network (SWHR CIN) is an affiliated company of Texas Health and UT Southwestern. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health or UT Southwestern employee.
Qualifications
Education
Other- Graduate of an accredited School of Nursing, LVN required
Experience
2 years utilization management experience in an acute or post-acute provider, health plan or other care company required and
2 years experience in direct patient care as an LVN, preferred acute care required and
5 years experience in health plan utilization review, discharge planning and medical case management preferred
Licenses and Certifications
LVN - Licensed Vocational Nurse (Possession of current Licensed Vocational Nurse license in state of hire) upon hire required
Position Responsibilities
Accountable for performing initial, concurrent, or post service review activities; discharge care coordination; and assisting with efficiency and quality assurance of medical necessity reviews in alignment with Federal, State, Plan, and Accreditation standards. The UM reviewer serves as a liaison between providers/ facilities and Care Management Division. This position does support working from home for eligible employees and will follow the Telecommuting policy for requirements and eligibility.
Supports the Collaborative Care Management Model as a working partner with registered nurses, physicians, social workers, pharmacists and other professional staff.
Accurately applies decision support criteria.
Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively.
Demonstrates an understanding of funding resources, services and clinical standards and outcomes.
Demonstrates knowledge of case management standards of practice and processes including identification and assessment, planning, interventions and evaluation.
Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals.
Demonstrates a solid understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization and outcomes of the different methods of reimbursement.
Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address utilization/resource and progression of care issues. Assists in developing and implementing an improvement plan to address issues.
Implements discharge plan to prevent avoidable days or delays in discharge.
Transitions patients to next level of care in coordination with facility Discharge Planner.
Identifies and refers complex risk members to case management.
Completes documentation in a timely, complete, and accurate manner in accordance with: (a) eligibility and benefits, (b) clinical guidelines/criteria, (c) legal and regulatory requirements.
Identifiy documents and refer cases to the Physician Advisor for medical review when services do not meet medical necessity criteria, and/or appropriate level of care, and/or potential quality issues.
Supports the mission statement, policies and procedures of the organization. Assists in eliminating barriers to achieve integrated, efficient and quality service. Complies with all compliance, regulatory and process training within the specified timeline. Serves as a resource to employees and customers as demonstrated by visibility and knowledge of issues. Utilizes resources efficiently and effectively. Maintains safe environment. Participates in Performance Improvement activities. Maintains objectivity in decision making, utilizing facts to support decisions.
