Utilization Review Specialist - LPN

• Act as liaison between managed care organizations and the facility professional clinical staff.
• Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
• Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
• Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls between facility and external organizations.
• Initiate and complete the formal appeal process for denied admissions or continued stay.

Experience

• Associate's degree in nursing (LPN) required.

• Two or more years' experience with the population of the facility and previous experience in utilization management preferred.
• Bachelor's or Master’s degree in social work, behavioral or mental health, nursing or other related health field preferred.

Education

• Associates or better in Nursing/Healthcare

• Masters or better in Social Work or related field
• Bachelors or better in Social Work or related field

Licenses & Certifications

• Lic Practical Nurse

Skills

• Computer - Word
• Computer - Powerpoint
• Computer - Excel
• Typing
• Attention to Detail

Behaviors

• Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well
• Dedicated: Devoted to a task or purpose with loyalty or integrity

Motivations

• Goal Completion: Inspired to perform well by the completion of tasks
• Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)