Utilization Management Nurse Reviewer LPN (Work at Home for FL residents only)

LPN Utilization Management Nurse Reviewer Miami, FL (Work from Home position for FL residents only) Currently seeking an LPN FL licensed Utilization Management Nurse Reviewer for a great opportunity working from home at a dynamic healthcare organization based in Miami, FL area. The ideal candidate will possess 3 years of experience managing the treatment plan and utilization for members receiving Home Health Care / Infusion Services and Durable medical equipment and supplies. JOB SUMMARY: Manages the treatment plan and utilization for all members receiving Home Health Care / Infusion Services and Durable medical equipment and supplies. Conducts the review process for those requests that appear not to be medically necessary; facilitates, coordinates and evaluates the ongoing care of a specific caseload of patients to collaborate with physicians, the patient and the family to assure cost-effective, high quality, appropriate home care for the patient during the entire episode of illness and for post discharge services and to monitor and evaluate patient outcomes, including self-management. ESSENTIAL JOB FUNCTIONS: Duties of the Utilization Review Nurse / Home Health Case Manager include but are not limited to: o Receive updated orders and medical information from all referral sources, i.e. Hospitals, Physician’s offices, Skilled Nursing Facilities, Rehabilitation Centers, Health Plans, PHOs, CM Departments, Home Health Agencies and others. o Perform clinical review, to ensure that pre-established medical necessity/appropriateness criteria are met. o Refer reviews that do not meet coverage criteria to Medical Director and/or Health Plan. o Review and evaluates home health admission for clinical appropriateness of the continued care. o Identifies and engages patients in appropriate care. o Develop coordinated, collaborative care plans with all involved providers. o Perform reviews telephonically using the member’s medical records, discussion with the member’s physician and/or discussion with Home health agency staff. o Facilitate timely discharges and transfers based on individual needs and care requirements o Educate patients to help them understand their health choices and assist them in making informed decisions about their health care. o Serve as information resource and liaison to patients, health care professionals, facilities, health plan representatives, care givers, agencies and family members. o Monitor cost-effective use of resources. o Monitor health care service delivery and utilization according to the plan of care o Provide authorizations and notifications in a timely manner. o Maintain/update active patient list o Document and resolve first line patient treatment plan. o Prepare concise clinically based rationales that support clinical criteria such as: CMS, Medicaid, Health Plan Benefits, and InterQual o Maintain a working knowledge of, and adheres to applicable federal/state regulations including but not limited to, laws related to patient confidentiality, release of information, and HIPAA o Input the pertinent information and authorization into the appropriate software o Maintain files. o Participate in department meetings and in-services PHYSICAL REQUIREMENTS: 1. The physical activities of this position involve fingering, grasping, talking, hearing, repetitive motions that may include the wrists, hands and/or fingers, sedentary work. 2. The physical demands of this position involve sedentary work constantly remaining in a stationary position, sitting for prolonged periods of time. 3. It may include exerting up to 10 pounds of force occasionally to lift, carry, push, pull or otherwise move objects, including the human body. 4. Constantly communicating with others to express or exchange information by means of the spoken word and/or in writing. 5. The visual acuity requirements of this position involve (including color, depth perception, and field of vision) to have close visual acuity to perform an activity such as: preparing and/or analyzing data and figures; constantly viewing a computer terminal and/or extensive reading. 6. Working Conditions of this position involve constant typical office or administrative work. No adverse environmental conditions expected. MINIMUM QUALIFICATIONS: 1. LPN license required 2. 3 years of Home Health Managed Care experience. 3. Medicare/Medicaid Managed Care experience 4. Experience with InterQual (IQ), Milliman Care Guidelines (MCG) or other criteria used to determine medical necessity preferred. 5. Possess excellent customer service skills. 6. Bilingual (English/Spanish) preferred. 7. Effective verbal and written communication skills. 8. Proficient in MS Outlook, MSWord and Internet Explorer. 9. WAH (Work at Home) Requirements - Must have reliable high-speed internet. Minimum standard speed for optimal performance of 10 x 1 (10mbs download x 1mbs upload) required. Must have a separate private workspace / desk area