UM Resource Coord LVN - Utilization Mgmt - SCMG - Days - FT
Company: SHARP HEALTHCARE
Location: San Diego
Posted on: April 24, 2024
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Job Description:
HoursShift Start Time:8 AMShift End Time:5 PMAdditional Shift
Information:7AM to 6PMWeekend Requirements:No WeekendsOn-Call
Required:NoHourly Pay Range (Minimum - Midpoint - Maximum):$27.986
- $34.983 - $41.979 -The stated pay scale reflects the range that
Sharp reasonably expects to pay for this position.--- The actual
pay rate and pay grade for this position will be dependent on a
variety of factors, including an applicant's years of experience,
unique skills and abilities, education, alignment with similar
internal candidates, marketplace factors, other requirements for
the position, and employer business practices. - -
What You Will Do
The UM Resource Coord-SCMG serves as a resource to the various
teams in the SCMG UM Department. Prepares referral requests for
outpatient services, elective inpatient admissions, skilled nursing
facility admissions, durable medical equipment (DME), and home
health, utilizing health plan web sites to obtain benefit
verification information and medical necessity criteria. Support
SCMG provider practices in facilitating referrals for services for
members in a timely manner in observance of regulatory
requirements. Responsible for UM adverse determination letters to
include ensuring compliance with appropriate reading level and
regulatory agency requirements. Performs clinical/medical necessity
reviews and authorizes medical services that meet medical criteria.
The review of care is region specific and consists of outpatient
healthcare services on pre-certification requests, outpatient
procedures, outpatient services, elective inpatient admissions,
home health services, genetic testing, orthotics, prosthetics and
complex durable medical equipment. Facilitates referrals to
providers or vendors that are region specific while determining
medical necessity and appropriateness.
Required Qualifications
Preferred Qualifications
Essential Functions
Navigates health plan web sites.
Verify member eligibility status.
Obtain detailed benefit coverage for service requests in accordance
with the member's benefit plan coverage.
Accurately interpret health plan benefits.
Apply the benefit guidelines to approve referral requests as
outlined in the SCMG prior authorization document and desktop
procedures.
Research and assist in the benefit denial process by utilizing SCMG
operational documents to obtain necessary documentation, such as
member specific health plan Evidence of Coverage (EOC), health plan
coverage criteria, etc.
Obtain necessary medical/clinical information utilizing multiple
sources including use of specific medical group electronic health
records by following SCMG documented operational processes.
Accurately interpret external criteria and internal operational
documents.
Ensure medical necessity criteria selected is appropriate for the
referral request being reviewed.
Document in the referral management system, according to SCMG
operational processes, actions taken on each referral processed
including, but not limited to telephone calls made to obtain needed
information, documentation of actions taken related to the
processing of the referral.
Consults with supervisor, team lead and/or medical director to
discuss requests/care inconsistent to criteria and determine the
appropriateness of service/care.
Attach corresponding documents to the referral within the referral
management system in OnBase, the document management system.
Reviews for medical necessity and appropriateness of services/care
based on health plan members medical condition, with the
utilization of evidence-based criteria (MCG, Medicare, Health plan
and other approved criteria)
Authorizes the correct vendor to provide care services reviewing
risk matrix and health plan contracted vendor list.
Communicates decisions to the requesting provider, facility and
member within department's approved guidelines.
Triage ACES Contact Us emails, Customer Service emails and CSRs,
and Network Management referral requests.
Responsible for completion of correspondence to include approval
and adverse determination letters to in observance of the Flesch
Kincaid reading level as required by regulation.
Complete and maintain identified standard UM reports as identified
by the UM leadership team based on referral activities that are
necessary for assessing and monitoring effectiveness and accuracy
of managing referrals.
Communicate effectively, both orally and in writing, with all
levels of management, medical staff and patients.
Assist in conflict management and resolution as appropriate.
Manage time effectively by applying organizational, critical
thinking, analytical, patient care evaluation, and problem solving
techniques.
Achieve 90% or greater quarterly audit results.
Complete tasks accurately with minimal supervision.
Complete work and assigned tasks within specified timeframes.
Maintain the established performance metric of designated average
volume of referrals per day.
Keep current knowledge and understanding of applicable
accreditation and regulatory statutes related to health care,
managed care, as it related to the position.
Bring to attention of leadership, areas of non-compliance and
provide input on actions for improvement.
Serve as a resource and mentor to Health Services teams and other
department staff.
Establish mutually derived annual goals and meet goals.
Maintain individual in-service/performance records.
Attend and actively participates in department/team process/quality
improvement activities.
Knowledge, Skills, and Abilities
Sharp HealthCare is an equal opportunity/affirmative action
employer. All qualified applicants will receive consideration for
employment without regard to race, religion, color, national
origin, gender, gender identity, sexual orientation, age, status as
a protected veteran, among other things, or status as a qualified
individual with disability or any other protected class
California Licensed Vocational Nurse (LVN) - CA Board of Vocational
Nursing & Psychiatric Technicians
Keywords: SHARP HEALTHCARE, National City , UM Resource Coord LVN - Utilization Mgmt - SCMG - Days - FT, Other , San Diego, California
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