About the Job General Summary of Position LPN Utilization Manager provides support for the Care Management Department by coordinating and promoting comprehensive, quality, cost-effective care. Utilization and prior authorization background strongly preferred. Primary Duties and Responsibilities Assists in the identification of potential Case Management candidates through clinical review selected diagnoses etc. and makes appropriate referrals.
Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations. Demonstrates behavior consistent with MedStar Health mission vision goals objectives and patient care philosophy.
Identifies and reports potential coordination of benefits subrogation third party liability workers compensation cases etc. Identifies quality risk or utilization issues to appropriate MedStar personnel. Initiates contact with providers to obtain clinical information to facilitate care or pending pre-certification requests.
Interacts with assigned disease management populations of limited volume. Interaction is designed to improve patient access to care and education regarding the disease and support services. Maintains current knowledge of MedStar Family Choice benefits and enrollment issues in order to accurately coordinate services.
Maintains expertise in general benefit management and serves as a resource for MedStar Family Choice members physicians and staff for benefit interpretation and coordination. Maintains timely and accurate documentation in the IS System per Case Management policy. Participates in meetings work groups etc. as assigned.
Processes pre-authorizations for medical necessity LOC covered benefits and participation of the provider at the discretion of the guidelines and Medical Reviewer. Sends reviews to Medical Reviewer as appropriate. Coordinates review decisions and notifications per policy.
Minimal Qualifications Education Valid LPN License in the State of Maryland. required Experience 1-2 years Utilization review experience required and 3-4 years Diverse clinical experience required Licenses and Certifications LPN - Licensed Practical Nurse - State Licensure Valid LPN license in the State of Maryland or District of Columbia. Upon Hire required Knowledge Skills and Abilities Knowledge of current trends in healthcare delivery and utilization review criteria.
Ability to use computer to enter and retrieve data. Ability to create edit and analyze (Word Excel and PowerPoint) preferred This position has a hiring range of USD $32.71 - USD $53.49 /Hr.