Birmingham: Precert, Lpn
HealthSpring (Birmingham, Alabama)

This job posting has expired.

You may wish to try a search for Birmingham: Precert, LPN

Or visit the FlipDog home page
 

HealthSpring of Alabama, Inc. is dedicated to improving the health of the community we serve by delivering the highest quality and greatest value in health care benefits and services. We are seeking an experienced Outpatient Utilization Review Nurse, LPN for our Health Services Department in our Birmingham office.

Primary Function:
Responsible for the effective and sufficient support of all utilization management activities to include prospective/pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies.

Responsibilities:
Performs all utilization review activities according to Health Services Policy and Procedures. Contacts providers as appropriate to obtain necessary information.
Evaluates and authorizes the medical necessity of inpatient and outpatient services as assigned by application of approved criteria and established policies and guidelines.
Notifies hospital and/or provider of recommended changes in level of care when applying approved criteria and established policies and guidelines.
Refers cases to the Medical Director/Physician Advisor as appropriate.
Enters all information into the health plans computer documentation system ensuring complete and accurate information in a timely manner.
Notifies hospital and/or providers of all denials and generates denial letters when recommended by the Medical Director/Physician Advisor.
Evaluates each case for quality of care, documents quality issues and appropriately refers cases to the quality management coordinator.
Reviews selected claims and retrospective requests for certification and follow-up as necessary with the UM Manager or Medical Director.
Participates in education of providers regarding Health Services policies and procedures.
Identifies and refers cases to the case management or disease management department as appropriate.
Assists with discharge planning.
Maintains strong working relations with internal and external customers. Presents all communication in a positive and professional approach.
Attends and actively participates in weekly staff meetings.
Maintains confidentiality in all aspects of operations.
Assist the Outpatient Manager and/or Health Services Vice President in tasks as assigned.

Supervisory Responsibilities:
None

Job Related Skills:
Communicates information accurately, timely to internal and external staff. Written and oral communication is accurate and timely and at the appropriate level.
Ability to articulate clinical and non-clinical information to personnel of all levels of understanding.
Ability to communicate with team members continuously and in a positive manner.
Assist education of internal and external staff in operations, policies and procedures, and regulator standards.
Ability to handle multiple tasks, set priorities and develop action items.
Detail oriented, excellent organizational skills, highly self-motivated and dependable.
Team and goal oriented.

Experience:
Current Licensure as a Practical Nurse in the State of Alabama.
2-3 years clinical experience with at least 1-2 years in utilization review preferred.
Managed Care experience preferred
Knowledge of ICD-9 and CPT coding guidelines for utilization review preferred.

HealthSpring offers a competitive salary and full range of benefits. Please remember to include Resume and salary requirements.

Please apply via the URL: https://home.eease.com/recruit/?id=42230

 No phone call accepted.

HealthSpring of Alabama, Inc. is an EEO/AA employer.