Utilization Manager Licensed Vocational Nurse - LVN - SWHR CIN - Fort Worth

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LVN
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20011083 Requisition #
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Southwestern Health Resources is seeking to hire a Utilization Manager Licensed Vocational Nurse to support our Southwestern Health Resources Utilization Management Department.

 

The address is 900 Jerome St, Suite 400, Fort Worth, Texas 76104

 

Salary range is $21.69/hour – Max 35.09/hour – based on relevant experience.

 
Work Schedule

• Full-time: 40 hours per week, Days, 8am-5pm

 

Accountable for performing initial, concurrent, or post service review activities; discharge care coordination; and assisting with efficiency and quality assurance of medical necessity reviews in alignment with Federal, State, Plan, and Accreditation

standards. The UM reviewer serves as a liaison between providers/ facilities and Care Management Division. This position does support working from home for eligible employees and will follow the Telecommuting policy for requirements and eligibility. The essential job duties for this position are:

 

 Supports the Collaborative Care Management Model as a working partner with registered nurses, physicians, social workers, pharmacists and other professional staff.

•  Accurately applies decision support criteria.

•  Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively.

•  Demonstrates an understanding of funding resources, services and clinical standards and outcomes.

•  Demonstrates knowledge of case management standards of practice and processes including identification and assessment, planning, interventions and evaluation.

•  Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals.

•  Demonstrates a solid understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the

effect on utilization and outcomes of the different methods of reimbursement.

•  Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address utilization/resource and progression of care issues. Assists in developing and implementing an improvement plan to address issues.

•  Implements discharge plan to prevent avoidable days or delays in discharge.

•  Transitions patients to next level of care in coordination with facility Discharge Planner.

•  Identifies and refers complex risk members to case management.

•  Completes documentation in a timely, complete, and accurate manner in accordance with: (a) eligibility and benefits, (b) clinical guidelines/criteria, (c) legal and regulatory requirements.

•  Identifiy documents and refer cases to the Physician Advisor for medical review when services do not meet medical necessity criteria, and/or appropriate level of care, and/or potential quality issues.

•  Supports the mission statement, policies and procedures of the organization. Assists in eliminating barriers to achieve integrated, efficient and quality service. Complies with all compliance, regulatory and process training within the specified timeline.

•  Serves as a resource to employees and customers as demonstrated by visibility and knowledge of issues.

•  Utilizes resources efficiently and effectively. Maintains safe environment.

•  Participates in Performance Improvement activities.

•  Maintains objectivity in decision making, utilizing facts to support decisions.

•  Perform other duties as assigned.


The ideal candidate will possess the following qualifications:


  Graduate from an accredited School of Nursing, LVN


  2 Years of experience Utilization management experience in an acute or post-acute provider, health plan or other care company required.


  2 Years of experience in direct patient care as an LVN, preferred acute care, required and,


  5 Years of experience in health plan utilization review, discharge planning and medical case management preferred.


  LVN – Licensed Vocational Nurse Possession of current Licensed


Vocational Nurse license in state of Hire required.


 



Skills:


  Understands limitations of licensure for LVN. Works collaboratively with RN for out of scope deliverables.


  Knowledge of specific regulatory, managed care requirements, and strong attention to detail.


  Working knowledge of computers and basic software applications used in job functions such as word processing, graphics, databases, spreadsheets, etc.


  Knowledge of Milliman Guidelines or similar clinical guidelines.


  Strong analytical and organizational skills.


  Working knowledge and ability to apply professional standards of practice in work environment.


Southwestern Health Resources Clinically Integrated Network (SWHR CIN) is a partner company of Texas Health. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health employee.


 


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