UM LVN

Where compassion meets innovation and technology and our employees are family.

Thank you for your interest in joining our team! Please review the job information below.


GENERAL PURPOSE OF JOB:
The UM LVN is responsible for the coordination and facilitation of member health services. This position provides support to the Utilization Management (UM) Department to ensure referrals/authorizations, phones calls, and interdepartmental communications are addressed and completed in a timely manner.
The UM LVN coordinates member needs through communication with the physician offices, member's family, Population Health Department, or other departments and other members of the health care team

ESSENTIAL DUTIES AND RESPONSIBILITIES:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by Health Plan leadership, as required.

Utilization Review LVN Responsibilities:
Knowledge:
1. Knowledge in Texas Medicaid criteria/guidelines preferred.
2. Knowledge of programs and services required to support the health and medical needs of disabled children preferred.
3. Knowledge of various reimbursement mechanisms, including third party requirements preferred.

Skills:
1. Requires a well-organized individual with an excellent capacity for effective time management.


2. Demonstrates ability to establish and maintain effective working relationships with the provider office staff and peers.
3. Demonstrates ability to operate personal computer programs as well as complex medical management software.
4. Strong Microsoft Office skills preferred.
5. Excellent communication skills.
6. Basic Microsoft Office skills.
7. Maintains utmost level of confidentiality at all times.
8. Maintains compliance with regulatory agencies that conduct intermittent reviews and audits to ensure contractual and regulatory compliance with Federal, State entities as well URAC.
9. Implements and adheres to Health System and Health Plan policies and procedures for members with special health care needs (STAR Kids).
10. Demonstrates business practices and personal actions that are ethical and adhere to Corporate Compliance and integrity guidelines

Responsibilities:
1. Review authorization requests for completeness of information.
2. Access various databases in order to determine member needs for services
3. Submit appropriate requests to medical directors for review.
4. Process complex authorization requests according to decision-making tool (Authorization Guide) to include forwarding information to Case Managers and medical director as appropriate.
5. Ability to work independently and as part of a team.
6. Collection and transfer of data and input of various types of information into the various Medical Management Systems.
7. Understand how to process or distribute authorizations which are lacking information.
8. Maintain authorization turn-around-time stats.
9. Coordinates care and efficient utilization of health care resources for patients identified in the STAR Kids program through communication with other members of the health care team, including physician offices, social workers, nurses, and other multidisciplinary team members as appropriate to obtain optimal outcomes for members.
10. Provide the member with initial and ongoing assistance identifying, selecting, obtaining, coordinating, and using services and supports to enhance wellbeing, independence, integration into the community, and potential for supportive employment.
11. Enters LTSS authorizations into the system per the direction of the Service Coordinators in the SCIP.
12. Communicates with management regarding status of current workload and turn-around time discrepancies as necessary.
13. Must obtain approval from manager or designee to any redistribution of workload.
14. Ensure thorough knowledge of the STAR Kids contract and meet all Service Coordination contract requirements.
15. Participates in health plan committees as appropriate and on request.
16. Accepts other assignments from management as requested and complies with basic management principals of delegation.

EDUCATION AND/OR EXPERIENCE:
• Experience in a managed care organization, or government agency such as DADS, DSHS, etc. with Long Term Support Services, and care coordinator experience highly preferred.
• Licensed Vocational Nurse
• Minimum 3 years of clinical experience (pediatric preferred) or 1 year experience in managed care.
• Previous experience with the State of Texas STAR Kids, STAR+PLUS, or similar programs preferred.
CERTIFICATES, LICENSES, REGISTRATIONS:
A current, active, and unrestricted Licensed Vocational Nurse license in the State of Texas.