LVN/LPN Care Advisor- Utilization Management (REMOTE)

    • Contract
  • Wilmington, DE
  • 36.50/h


100% Remote – ANY timezone is OK

Shift: This is a weekend shift.
****Candidates must work every Friday/Saturday/Sunday.
They can select the other days and can either work 4 10 hr shifts or 5 8 hour shifts.

Reviewing outpatient cases and comparing criteria.
This is not a call center role, low phone volume. May occasionally speak to a provider if needed.

Candidates must have some UM experience – please ensure UM experience is listed on qualifications.

Who You’ll Be Working With:

The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks are performed within the LVN/LPN scope of practice, under Medical Director direction, using independent nursing judgement and decision-making, physician-developed medical policies, and clinical decision-making criteria sets. Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost effective care delivery.

What You’ll Be Doing:

· Performs utilization review of outpatient procedures and ancillary services.

· Fulfills on call requirements for selected clients as scheduled.

· Determines medical necessity and appropriateness of services using clinical review criteria.

· Accurately documents all review determinations and contacts providers and members according to established timeframes.

· Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director.

· Appropriately identifies and refers quality issues to UM Leadership.

· Appropriately identifies potential cases for Care Management programs

· Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum.

· Performs accurate data entry.

· Communicates appropriate information to other staff members as necessary/required.

· Participates in continuing education initiatives.

· Collaborates with Claims, Quality Management and Provider Relations Departments as requested.

· Availability on some weekends and holidays may be required

· Performs other duties as assigned.

The Experience You’ll Need (Required):

· State of Illinois practical/vocational nurse license (current and unrestricted)

· High School Diploma or equivalent required

· UM Experience

· Minimum of three years of direct clinical patient care

· Minimum of one year of experience with medical management activities in a managed care environment

Finishing Touches (Preferred):

· Knowledge of managed care principles, HMO and Risk Contracting arrangements.

· Knowledge of health care resources within the community

· Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual)

· Strong interpersonal, oral and written communication skills.

· Possess basic computer skills

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