Remote Utilization Review LPB- Home Health
Posting ID: JP-002663344
• Performs an initial evaluation of the referrals appropriateness for company Services. Reviews for information needed to make a medical necessity determination. Requests additional clinical information when needed to render a decision and determines next steps.
• Using clinical expertise, reviews clinical information and clinical criteria to determine if the service/device meets medical necessity for the patient.
• Ensure case review and elevation to complete the determination is rendered within the contractual and regulatory turnaround time standards to meet both contractual and regulatory requirements.
• Interact with the Medical Director as needed to ensure proper medical necessity decisions are being made in a timely manner.
• Acts as a clinical resource to department care coordinators, providing expertise and clinical support.
• Develops/maintains a working knowledge of all services/guidelines/policies and accesses contract information, including the terms of the contract as appropriate.
• Manages multiple tasks, is detail oriented, responsive, and demonstrate independent thought and critical thinking.
• Reviews and adheres to all Company policies and procedures and the Employee Code of Conduct.
Clinical review, utilization review, utilization management, home health, LPN, licensed practical nurse, McKesson, InterQual, MCG, milliman, Managed care
Top Skills Details:
Clinical review,utilization review,utilization management,home health
Additional Skills & Qualifications:
• Associate's Degree or Diploma in Nursing/Practical Nursing required
• Must be a Registered Nurse/LPN/LVN or RT with Licensure in the state(s) of practice (based on allowable state practice act) is required during time of employment.
• Current and unrestricted license required.
• Minimum of 2 years of experience in a clinical setting required.
• Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/review experience, and governmental home health agency regulations preferred.
• Excellent negotiation, communication, problem solving and decision making skills also preferred.
Actalent connects passion with purpose. Our scalable talent solutions and services capabilities drive value and results and provide the expertise to help our customers achieve more. Every day, our experts around the globe are making an impact. We’re supporting critical initiatives in engineering and sciences that advance how companies serve the world. Actalent promotes consultant care and engagement through experiences that enable continuous development. Our people are the difference. Actalent is an operating company of Allegis Group, the global leader in talent solutions.
The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
Recruiter: Alexa Guirand