Universal American
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Pre-Cert Nurse LVN

Job Title
Pre-Cert Nurse LVN
Job ID
956467
Begin Date
6/22/15
Duration
Location
Houston,  TX
Other Location
Description
The Pre-Cert Nurse will review clinical documentation to determine the medical necessity of requested services by providers and members. Assist Medical Director in the organizational determination for services that do not meet medical necessity as well as in the assessment, management and appropriate intervention of those members requiring complex Case Management medical needs as well as preauthorization of service as per the Medical Management Department’s policies and procedures.  Help maximize the components of the in-patient and out-patient settings by utilizing medical necessity tools, criteria and protocols to:
 
  • Authorize services regarding the authorizations and implementation of approved services through Pre-cert and functions;
  • Provide members with the support, education and assistance in the prevention and/or maintenance of their disease and/or health and wellness state; and Improve collaborative coordination of care to affect waste and inefficiency.
Responsibilities:
  • Reviews service requests submitted by physicians to include review of evidence/clinical documentation and its medical necessity.
  • Communication with Health plan care managers for follow up needs with documentation in the Care Management system.
  • Facilitates provider contact as needed to coordinate member’s care needs.
  • Phone contact with identified members or providers to explain the program, assess needs, educate regarding the disease as appropriate, instruct the member how to access the program resources, suggests and/ or arranges follow-up including mailing of educational materials, contact with community resources, facilitating physician visits etc, and documenting the re-contact into the web-based system depending on the needs assessment.
  • Assess as needed the discharge planning needs regarding Home Health and/or elective procedures. Coordinating with facilities, Medical Management staff, providers and members.
  • Consults and works closely with the Medical Director regarding care that doesn’t appear to meet medical necessity.
  • Responsible for the documentation of all clinical decisions, to include the drafting and recording of denial letters to providers and members.
  • Conducts daily tracking of caseload as assigned.
  • Complies with all departmental policies and procedures.  Participates in departmental and company in-services as appropriate.
  • Complies with Customer Service expectations as applicable to the Department and Health Plan.
  • Assist in retroactive reviews done for the Claims department.
  • Take calls from members and providers and give them appropriate information to help expedite services.
  • Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable, and defined in the Universal American Corporate and department policies.
  • And all other duties assigned by the manager and/or supervisor.
Required Skills
  • Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas
  • Organizational skills with the ability to handle multiple tasks and/or projects at one time
  • Customer service skills with the ability to interact professionally and effectively with providers, third party payers, physicians, and staff from all departments within and outside the Company
  • Analytical and interpretation skills including departmental, utilization, financial and operations data
  • Decision-making skills with the ability to investigate and weigh alternatives and select the course of action that provides the greatest benefit to the organization
  • Creative thinking skills with the ability to ask the needed bigger-picture questions that lead to process and team improvements
  • Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time
  • Problem solving skills with the ability to look for root causes and implementable, workable solutions
  • Interpersonal skills with the ability to work in a fast-paced environment and participate as an independent contributor with little supervision or as an active team member depending on the situation and needs
  • Must have a track record of producing work that is highly accurate, demonstrates attention to detail, and reflects well on the organization
Required Experience                       
  • LVN with current Texas licensure
  • Associate’s degree minimum, Bachelor’s degree preferred
  • Two years’ utilization management or case management experience within a hospital, home health setting or managed care company preferred
  • Bilingual and experience with seniors, aged, blind and disabled is a plus
  • Personal computer experience should include working with Microsoft Word, Excel, PowerPoint and Outlook at the intermediate level at a minimum
  • Maintains a valid driver’s license for any required facility on-site and home visits
  • Associate’s degree minimum, Bachelor’s degree preferred
  • Two years’ utilization management or case management experience within a hospital, home health setting or managed care company preferred
  • Bilingual and experience with seniors, aged, blind and disabled is a plus
  • Personal computer experience should include working with Microsoft Word, Excel, PowerPoint and Outlook at the intermediate level at a minimum
  • Maintains a valid driver’s license for any required facility on-site and home visits

Work is performed in a professional office setting, business casual dress environment.  Working extended hours may be required as needed.
 
The physical demands for this position include exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently to lift, carry, push, pull or otherwise move objects, including the human body.  This is considered sedentary work, which involves sitting most of the time; walking and standing are required, as well on occasion.  Telephone work and/or computer work are typically required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Required Skills

LVN, Nurse, Analytical Skills, Time Management
Openings
1

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