HN58
HN58 - LPN/LVN
SUMMARY Works primarily with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and scripted algorithms within scope of licensure. This level works with more complex elements and requires review of more complex benefit plans. May also serve as a resource to less experienced staff. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment. MAJOR DUTIES AND RESPONSIBILITIES Conducts pre-certification, concurrent if not associated with CM or DM triage, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract. Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process. Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications. Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards. SKILLS: Requires oral and written communication skills, problem-solving skills, PC skills, and research and analytical skills. EDUCATION/EXPERIENCE Requires a minimum of an LPN or LVN with current licensure or certification in the appropriate state and 2 years clinical experience, recent utilization review experience or any combination of education and experience, which would provide an equivalent background. Requires at least 1 additional year of managed care experience and knowledge of the medical management process.