Utilization Management LPN

About the position

Adecco Healthcare & Life Sciences is seeking a dedicated and skilled Utilization Management LPN to join our team in a remote capacity. This position is a two-month contract with the potential for extension or a full-time offer, providing an excellent opportunity for those looking to advance their careers in healthcare. The Utilization Management LPN will play a crucial role in ensuring that prior authorization requests are reviewed and processed efficiently, adhering to both contractual and regulatory requirements. This role requires a proactive approach to coordinating the prior authorization review process for both outpatient and inpatient service requests, ensuring that all actions are taken within the scope of the LPN's license. In this position, the LPN will collaborate with the Case Management Department and other relevant departments as needed, ensuring that all prior authorization requests are handled accurately and thoroughly. The LPN will be responsible for conducting timely reviews of requests, which may include acute hospital pre-admissions, surgical and diagnostic procedures, therapies, durable medical equipment, and home health care. Utilizing nationally recognized and evidence-based guidelines, the LPN will make medical determinations in accordance with the policies and procedures established by the physician group Medical Directors and UM Committees. Additionally, the Utilization Management LPN will audit and evaluate patient medical records to determine benefit coverage and medical necessity, ensuring that the appropriateness and level of care are met. The role also involves assisting UM Coordinators and clerical staff with clinical interpretations and definitions, as well as helping patients understand the criteria used in determinations. The LPN will also assist in processing denial and extension letters, ensuring that the language used is appropriate and accessible to the health literacy level of the patients.

Responsibilities
• Ensure prior authorization requests are reviewed and completed in a timely manner.
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• Coordinate the prior authorization review process for outpatient and inpatient service requests.
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• Collaborate with the Case Management Department and other departments as needed.
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• Conduct accurate and thorough reviews of prior authorization requests.
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• Timely review of requests including acute hospital pre-admissions, surgical and diagnostic procedures, therapies, durable medical equipment, and home health care.
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• Make medical determinations based on evidence-based guidelines and approved policies.
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• Audit and evaluate patient medical records for benefit coverage and medical necessity.
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• Assist UM Coordinators and clerical staff with clinical interpretations and definitions.
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• Help patients understand the criteria used in determinations as requested.
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• Assist in processing denial and extension letters with appropriate language and criteria.

Requirements
• Active LPN license
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• Graduate of an accredited school of nursing
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• Bachelor's Degree in nursing or healthcare-related field or equivalent work experience
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• One year clinical experience in an acute or ambulatory patient care setting
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• One year experience in a managed care environment
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• Knowledge of Medicare, DMHC, NCQA, and MCG Guidelines
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• Proficient in Microsoft Office suites

Nice-to-haves

Benefits
• Weekly Pay
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• 401(k) Plan
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• Skills Training
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• Excellent medical, dental, and vision benefits
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• Life insurance
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• Short-term disability
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• Additional voluntary benefits
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• EAP program
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• Commuter benefits
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• Paid Sick Leave
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• Holiday pay where applicable

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