Utilization Management Nurse Reviewer LPN (Work at Home for FL residents only)

Coastal Care Services, Inc.; Miami (FL); Teletrabalho; USD 32 000 - 45 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Dental insurance

Disability insurance

Employee discount

Health insurance

Life insurance

Paid time off

Vision insurance

Resumo da oferta

Coastal Care Services, Inc. is seeking an LPN licensed Utilization Management Nurse Reviewer for a work-from-home opportunity serving the Miami, FL area.

Work schedule is 10am to 7pm, with every other Sunday and a weekday off for a total of five days per week. The role manages treatment plans and utilization for Home Health Care, Infusion Services, and Durable Medical Equipment, reviews medical necessity, collaborates with physicians, patients and families to assure cost-effective, high-quality

Qualificações

• LPN license required.
• 2+ years of Home Health Managed Care experience preferred.
• Experience with Medicare/Medicaid Managed Care.
• Familiarity with InterQual/MCG or other medical-necessity criteria.
• Excellent customer service and communication skills.
• Bilingual English/Spanish preferred.
• Proficient with MS Outlook, Word and internet research.
• Work-at-home requirements: reliable high-speed internet and private workspace.

Responsabilidades

• Manage treatment plans and utilization for Home Health/Infusion/DME patients.
• Conduct reviews to determine medical necessity and appropriateness.
• Coordinate with physicians, patients and families to ensure quality, cost-effective home care.
• Authorize and communicate care plans and changes in a timely manner.
• Maintain patient lists and document rationale for care decisions.

Conhecimentos

LPN license

Home Health Managed Care

Medicare/Medicaid Managed Care

InterQual/MCG criteria

Customer service

Bilingual (English/Spanish)

MS Outlook

Work from home setup

Formação académica

High school diploma or equivalent

Ferramentas

InterQual

Milliman Care Guidelines

Descrição da oferta de emprego

LPN Utilization Management Nurse Reviewer

Miami, FL (Work from Home position for FL residents only)

Currently seeking an LPN FL licensed Utilization Management Nurse Reviewer for a great opportunity working from home at a dynamic healthcare organization based in Miami, FL area. Work Schedule 10am to 7pm, working every other Sunday with a weekday off for a total of 5 days a week.The ideal candidate will possess 3 years of experience managing the treatment plan and utilization for members receiving Home Health Care / Infusion Services and Durable medical equipment and supplies.

JOB SUMMARY:

Manages the treatment plan and utilization for all members receiving Home Health Care / Infusion Services and Durable medical equipment and supplies. Conducts the review process for those requests that appear not to be medically necessary; facilitates, coordinates and evaluates the ongoing care of a specific caseload of patients to collaborate with physicians, the patient and the family to assure cost-effective, high quality, appropriate home care for the patient during the entire episode of illness and for post discharge services and to monitor and evaluate patient outcomes, including self-management.

ESSENTIAL JOB FUNCTIONS:

Duties of the Utilization Review Nurse / Home Health Case Manager include but are not limited to:

1. Receive updated orders and medical information from all referral sources, i.e. Hospitals, Physician's offices, Skilled Nursing Facilities, Rehabilitation Centers, Health Plans, PHOs, CM Departments, Home Health Agencies and others.
2. Perform clinical review, to ensure that pre-established medical necessity/appropriateness criteria are met.
3. Refer reviews that do not meet coverage criteria to Medical Director and/or Health Plan.
4. Review and evaluates home health admission for clinical appropriateness of the continued care.
5. Identifies and engages patients in appropriate care.
6. Develop coordinated, collaborative care plans with all involved providers.
7. Perform reviews telephonically using the member's medical records, discussion with the member's physician and/or discussion with Home health agency staff.
8. Facilitate timely discharges and transfers based on individual needs and care requirements
9. Educate patients to help them understand their health choices and assist them in making informed decisions about their health care.
10. Serve as information resource and liaison to patients, health care professionals, facilities, health plan representatives, care givers, agencies and family members.
11. Monitor cost-effective use of resources.
12. Monitor health care service delivery and utilization according to the plan of care
13. Provide authorizations and notifications in a timely manner.
14. Maintain/update active patient list
15. Document and resolve first line patient treatment plan.
16. Prepare concise clinically based rationales that support clinical criteria such as: CMS, Medicaid, Health Plan Benefits, and InterQual
17. Maintain a working knowledge of, and adheres to applicable federal/state regulations including but not limited to, laws related to patient confidentiality, release of information, and HIPAA
18. Input the pertinent information and authorization into the appropriate software
19. Maintain files.
20. Participate in department meetings and in-services

PHYSICAL REQUIREMENTS:

1. The physical activities of this position involve fingering, grasping, talking, hearing, repetitive motions that may include the wrists, hands and/or fingers, sedentary work.
2. The physical demands of this position involve sedentary work constantly remaining in a stationary position, sitting for prolonged periods of time.
3. It may include exerting up to 10 pounds of force occasionally to lift, carry, push, pull or otherwise move objects, including the human body.
4. Constantly communicating with others to express or exchange information by means of the spoken word and/or in writing.
5. The visual acuity requirements of this position involve (including color, depth perception, and field of vision) to have close visual acuity to perform an activity such as: preparing and/or analyzing data and figures; constantly viewing a computer terminal and/or extensive reading.
6. Working Conditions of this position involve constant typical office or administrative work. No adverse environmental conditions expected.

MINIMUM QUALIFICATIONS:

1. LPN license required
2. 3 years of Home Health Managed Care experience.
3. Medicare/Medicaid Managed Care experience
4. Experience with InterQual (IQ), Milliman Care Guidelines (MCG) or other criteria used to determine medical necessity preferred.
5. Possess excellent customer service skills.
6. Bilingual (English/Spanish) preferred.
7. Effective verbal and written communication skills.
8. Proficient in MS Outlook, MSWord and Internet Explorer.
9. WAH (Work at Home) Requirements - Must have reliable high-speed internet. Minimum standard speed for optimal performance of 10 x 1 (10mbs download x 1mbs upload) required. Must have a separate private workspace / desk area designated for home office to ensure absolute and continuous privacy while at work.

The company is an Equal Opportunity Employer, in accordance with State and federal law. Coastal does not discriminate in employment opportunities or practices on the basis of race, color, religion, sex, national origin, age, disability, sexual orientation or any other characteristic protected by law. Opportunity is provided to all employees based on qualifications and job requirements.

We are a Drug-Free Work Place, we test for THC. This position is contingent upon completion and passing of a drug screening, verification of previous employment and a Level 2 Criminal Background check (please refer to the following website for more information and details on the Florida Care Provider Background Screening Clearinghouse: https://info.flclearinghouse.com.

No relocation/Local candidates only (FL state)

Job Type: Full-time

Pay: From $28.00 per hour

Benefits:

• Dental insurance
• Disability insurance
• Employee discount
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Application Question(s):

• What are your minimum salary expectations per hour?
• Are you willing to undergo a background check, in accordance with local law/regulations?
• Are you able to work holiday rotation once a year?
• Are you able to work 10:00am-7:00pm and work every other Sunday with a weekday off; working 5 days total/week?

Education:

• High school or equivalent (Preferred)

Experience:

• InterQual, Milliman Care Guidelines or other similar: 1 year (Preferred)
• home health and managed care: 1 year (Required)
• concurrent and retrospective UM related functions: 1 year (Required)
• Utilization review / medical necessity for home health: 1 year (Required)
• Utilization review / medical necessity for DME: 1 year (Required)
• prior authorization UM review: 1 year (Required)

Language:

• English and Spanish fluently (Preferred)

License/Certification:

• LPN clear and active for the state of FL (Required)

Work Location: Remote