Utilization Management LPN/LVN
Location
Melbourne, FL | United States
Job description
Pay Range: $24.04 - $32.21/hour
Actual base pay will be determined based on a successful candidate's work location, skills/abilities, experience, and education. This role includes opportunity to receive an annual bonus target of 5% of annual eligible earnings. Actual bonus amounts are determined by length of time in role, individual performance, and organizational performance.
States we employ in: AL, AZ, CO, FL, GA, IL, IN, KY, MO, NC, OH, OK, SC, SD, TN, TX, VA, WI, WV. In order for your candidacy to be considered, you must have established residency in one of these states or being willing to relocate.
If you live within 50 miles of either the Melbourne, FL or Colorado Springs, CO office, you would be expected to work onsite 3 days per week.
Who We Are At Christian Care Ministry (CCM) we believe that Christians can, and should, share in one another's burdens. Through the use of Medi-Share®, a healthcare sharing ministry for Christians, we cultivate that belief.
The Team Everyone at Christian Care Ministry agrees to our Statement of Faith which outlines our core beliefs. Although we aren't perfect people, we are serving our perfect God to the best of our ability.
The Role The Utilization Management LPN/LVN ensures that Medi-Share members who need inpatient and/or outpatient medical services receive high quality, cost-efficient care to achieve optimum clinical outcomes. Employing utilization management best practices, this role manages a diverse workload -- performing prospective, concurrent, and retrospective utilization management/review-related functions while adhering to the organization's governing guidelines and standard medical rules. This position will require the ability to work independently, in teams, and in multiple IT systems.
Essential Job Duties & Responsibilities - Works with leadership, clinical staff, key internal departments, and external customers to ensure optimum clinical outcomes for members
- Reviews and interprets members' medical records and compares against proprietary and evidenced-based criteria to determine eligibility for bill sharing and advocacy for additional programs and interventions; determines if the medical record documentation supports the eligibility of requested and/or billed services
- Performs abstracts review-related data/information accurately and timely in appropriate review systems by the appropriate means. Accurate and timely submission of all administrative and review-related documents to appropriate parties
- Performs ongoing reassessment of review process to offer opportunities for improvement and/or change.
- Reviews requests for genetic testing to determine eligibility for sharing and implements appropriate reimbursement strategies
- Advocates for members using the Medi-Share program to meet their health care needs
- Performs case reviews, checks medical records, speaks with patients and care providers regarding treatment, and collaborates with plan of care
- Reviews pre-notification of services and clinical information for care management intervention and medical appropriateness
- Performs clinical reviews paying close attention to the appropriateness of healthcare expenditures to include length of facility stays and outpatient therapy services
- Performs concurrent review and discharge planning for inpatients
- Provides for continuity of care
- Researches and assists in the negotiations for inpatients transitioning to different level of care
- Ensures appropriate levels of care are received by patients
- Provides appropriate consultation and referral to intra- and interdepartmental resources to ensure members receive optimum services offered by organization
- Manages assigned clinical caseload
- Performs administrative and clinical processes to ensure team and departmental goals are met
- Delivers accurate and comprehensible verbal and written communication to external customers while complying with organizational HIPAA requirements
- Maintains accurate and timely records of all communications and interventions
- Attends all required department and organization meetings
- Contributes to the exercise and expression of Christian Care Ministry's Christian beliefs
- All other duties as assigned
Essential Skills & Abilities - Expert knowledge of Medi-Share program guidelines and processes
- Strong organizational, prioritization, and process skills
- Advanced Excel skills; intermediate Microsoft office skills (Outlook, Teams, Word)
- Advanced knowledge of Salesforce, CSI/Eldorado use and documentation
- Excellent computer skills - ability to access, research and use multiple software programs simultaneously and keyboard skills of at least 35 words per minute
- Excellent research skills to using IT systems, internet, and phone
- Accurate data collection, documentation, and analysis - provides effective and efficient collection and distribution of research data without the need for supervision; able to correlate research findings with solutions
- Excellent ability to communicate effectively in written, oral, telephonic, and digital formats that build collaboration and facilitate positive outcomes
- Ability to work independently and with a team regularly; able to perform assigned special projects with minimal assistance
- Ability to comply with HIPAA, PHI, and all call compliance rules and regulations
- Excellent ability to provide all content within a Biblical framework
Core Competencies/Demonstrable Behaviors - Collaborates - builds partnerships and works collaboratively with internal departments, external healthcare providers, and members to meet objectives
- Optimizes Work Processes - knows the most effective and efficient processes to get results with a focus on continuous improvement
- Communicates Effectively - able to clearly and positively communicate needs and engage others to achieve objectives
- Action Oriented - enjoys the challenge of effecting savings and presents an attitude of willingness, enthusiasm, and urgency to meeting objectives
- Initiative - identifies what needs to be done with a willingness to take action
- Drives Results - consistently achieves and/or looks for opportunities to obtain and report results
Education and/or Experience - Current unrestricted compact LPN/LVN license with sound knowledge of anatomy and physiology, medical terminology, and disease processes required
- Graduate from an accredited Diploma, Associates Degree or Bachelor's Degree Program
- 2+ years of clinical experience and/or care coordination in an acute or med-surgical environment required.
- 1+ years working with EMRs and medical record/abstraction of data required
- Must be proficient in Microsoft Office and internet/web navigation and research required
Incentives & Benefits We work hard to serve our Medi-Share Members, but know we can only do that if we invest in our employees professionally, financially, physically, socially, and spiritually. We purposefully invest in our employees so that our employees can invest in others.
For full-time employees working 30 hours or more, some of our benefits include, but are not limited to:
- Medical
- Health Savings Account
- Employer Paid Life Insurance and Long-term Disability Insurance
- Dental
- Vision
- Short-term Disability
- Accident, Critical Illness, Hospital Indemnity
- 401(k) - up to 4% match
- Paid-time off - accrued bi-weekly
- Wellness plan
- Employee Assistance Program
- Anniversary Awards Program
- Birthday Awards
Job tags
Salary
