Part-Time, UM LVN

**Position Summary** The Utilization Management (UM) LVN is responsible for performing clinical review activities to support the prior authorization, concurrent review, retrospective review, and care coordination processes. Working within EZCAP and other clinical systems, the UM LVN applies evidence-based criteria and health plan guidelines to ensure medically necessary, appropriate, timely, and cost-effective healthcare services while maintaining compliance with CMS, DMHC, NCQA, and delegated health plan requirements. The UM LVN collaborates with physicians, providers, hospitals, case managers, and interdisciplinary staff to facilitate quality patient care and efficient utilization of healthcare resources. **Essential Duties and Responsibilities** **Utilization Management** - Perform clinical review of prior authorization requests using approved clinical criteria (MCG, InterQual, CMS, Health Plan guidelines, etc.). - Review outpatient, inpatient, DME, imaging, therapy, home health, and specialty referrals. - Determine whether requests meet medical necessity criteria within LVN scope of practice. - Identify cases requiring Medical Director review. - Escalate complex or questionable cases appropriately. - Monitor turnaround times to ensure compliance with regulatory requirements. - Prioritize expedited and urgent authorization requests. **Work Schedule** - Participate in a rotating schedule to provide Utilization Management coverage seven (7) days per week, including weekends and holidays, as assigned. - Work schedules will be adjusted to ensure compliance with applicable wage and hour laws and organizational scheduling practices. Weekend assignments will be balanced by scheduled days off during the workweek. - Respond to urgent and expedited authorization requests during assigned coverage periods to ensure compliance with CMS, health plan, and delegated entity turnaround time requirements. **Concurrent Review** - Perform continued stay reviews. - Monitor inpatient admissions and length of stay. - Coordinate discharge planning with Case Management. - Collaborate with hospitals regarding continued medical necessity. **Clinical Documentation** - Document complete and accurate clinical reviews in EZCAP. - Record medical necessity rationale. - Document provider communications. - Maintain detailed authorization notes. - Ensure documentation supports regulatory and audit requirements. **Provider Communication** - Contact provider offices to obtain additional clinical documentation. - Discuss authorization requirements. - Communicate approved services when appropriate. - Coordinate peer-to-peer review requests. - Educate providers regarding UM requirements. **Collaboration** - Work closely with: - Medical Directors - UM Coordinators - Case Managers - Provider Relations - Claims - Health Plans - Hospitals - Skilled Nursing Facilities - Home Health Agencies **Regulatory Compliance** Maintain compliance with: - CMS Medicare Managed Care Manual - DMHC Knox-Keene requirements - NCQA UM Standards - Health Plan Delegation Agreements - Organizational UM Policies - HIPAA Privacy Regulations **Quality Improvement** - Participate in internal audits. - Assist with corrective action plans. - Identify workflow improvements. - Participate in UM Committee initiatives. - Support delegation audit preparation. **EZCAP Responsibilities** - Review authorization queues. - Complete clinical review documentation. - Update authorization status. - Route cases requiring physician review. - Document medical necessity findings. - Generate authorization notes. - Review member eligibility. - Maintain accurate case records. - Monitor work queues. - Ensure timely processing of referrals. **Required Knowledge** Knowledge of: - Medical terminology - Disease processes - Medicare regulations - Managed Care principles - Prior Authorization process - Concurrent Review - Clinical documentation - Utilization Management - Health Plan guidelines - CMS requirements - HIPAA reg…