LPN Case Manager Clinical Authorization

MedStar Health’s Washington Hospital Center; Washington (District of Columbia); On-site; USD 45,000 - 74,000; Full time

Job summary

MedStar Health’s Washington Hospital Center is seeking an experienced LPN Case Manager to support the Care Management Department by coordinating quality, cost-effective care.

The role requires 1–2 years utilization review experience and 3–4 years diverse clinical experience; valid Maryland/DC LPN license; you will interact with providers, obtain clinical information, process pre-authorizations, and maintain IS system documentation.

Qualifications

• Valid LPN license in Maryland or DC; required at hire.
• 1-2 years utilization review experience; 3-4 years diverse clinical experience.
• Ability to use a computer to enter and retrieve data; experience with Word/Excel/PowerPoint preferred.

Responsibilities

• Assist in identifying candidates and refer appropriately.
• Coordinate benefits coordination and quality/utilization processes.
• Obtain clinical information from providers to support care and pre-certifications.
• Maintain timely documentation in the IS System per policy.
• Process pre-authorizations for medical necessity and covered benefits.

Skills

Utilization review knowledge

Clinical experience

Computer skills

MS Office suite

Education

LPN license - Maryland or DC

Tools

IS System

Microsoft Office

Job description

About the Job

General Summary of Position

LPN Case Manager provides support for the Care Management Department by coordinating and promoting comprehensive quality, cost-effective care.

Primary Duties and Responsibilities

• Assists in the identification of potential Case Management candidates through clinical review selected diagnoses etc. and makes appropriate referrals.
• Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
• Demonstrates behavior consistent with MedStar Health mission vision goals objectives and patient care philosophy.
• Identifies and reports potential coordination of benefits subrogation third party liability workers compensation cases etc. Identifies quality risk or utilization issues to appropriate MedStar personnel.
• Initiates contact with providers to obtain clinical information to facilitate care or pending pre-certification requests. Interacts with assigned disease management populations of limited volume. Interaction is designed to improve patient access to care and education regarding the disease and support services.
• Maintains current knowledge of MedStar Family Choice benefits and enrollment issues in order to accurately coordinate services.
• Maintains expertise in general benefit management and serves as a resource for MedStar Family Choice members physicians and staff for benefit interpretation and coordination.
• Maintains timely and accurate documentation in the IS System per Case Management policy.
• Participates in meetings work groups etc. as assigned.
• Processes pre-authorizations for medical necessity LOC covered benefits and participation of the provider at the discretion of the guidelines and Medical Reviewer.
• Sends reviews to Medical Reviewer as appropriate. Coordinates review decisions and notifications per policy.

Minimal Qualifications

Education

• Valid LPN License in the State of Maryland. required

Experience

• 1-2 years Utilization review experience required and
• 3-4 years Diverse clinical experience required

Licenses and Certifications

• LPN - Licensed Practical Nurse - State Licensure Valid LPN license in the State of Maryland or District of Columbia. Upon Hire required

Knowledge Skills and Abilities

• Knowledge of current trends in healthcare delivery and utilization review criteria.
• Ability to use computer to enter and retrieve data.
• Ability to create edit and analyze (Word Excel and PowerPoint) preferred

This position has a hiring range of

USD $32.71 - USD $53.49 /Hr.