U M NURSE-LPN - Forrest General Hospital

The LPN under general direction performs concurrent and retrospective reviews on all specified patients relative to the prospective payment system, Medicaid system, private review, and other hospital case mix applications. Assesses for medical necessity by screening available information against established levels of care screening criteria. Performs concurrent and retrospective review utilizing screen criteria such as McKesson Level of care criteria and MCG Guidelines Consults with attending physician and UM physician advisor regarding cases that are not meeting medical necessity for admission and continued stay and those meeting discharge criteria. Monitors observation cases daily according to the outlined procedure. Ensures timely reviews and notification to insurance payers. Compiles the clinical information needed to process prior authorization and continued stay requests and then documents in the electronic medical record. Reviews and documents relative information received via fax or telephone from payers in the electronic medical record such as DRG, reference number, LOS, next review dataset. Consistently follow-up on all pending authorization. Demonstrate the ability to obtain working diagnoses and procedure codes and a working DRG as needed. Develops and collects data and trends related to the utilization of health care resources. Follows all thirty party payer’s guidelines related to cultivation review. Monitors assigned cases for correct insurance, coordination of benefits, change in status, etc.. Reviews outpatient procedures for compliance with the APC “Inpatient Only” listing. Collaborates with Case Manager(s) on an ongoing basis. Knowledgeable of payer’s specific utilization program.

Functions as the central liaison between patient finance services, the registration department, the physician office’s staff, review agencies, and other healthcare professionals affected by concurrent review, DRG assignment, and the certification process. Records, reports and assists with all denials and appeals on assigned group of patients. Consistently document cases denied, and then follow-up with physician adagio and denial coordinator. Assists with scheduling peer to peer review. Demonstrates a working knowledge of IC-10 coding. Demonstrates knowledge and skills to appropriately communicate and interact with the patients, families, and visitors of all age groups while being sensitive to their cultural and religious beliefs.

Performance Expectations:

• Accomplishes work in ways that maximize productivity.
• Responds positively to and have to aptitude to deal with multiple task.
• Demonstrate the ability to manage daily workload.
• Adheres to various regulatory guidelines.
• Demonstrate the ability to learn and follow various regulatory guidelines.

Qualifications:

Education/Skills

Graduate of an accredited licensed practical nursing program. Must have successfully completed at least 770 clinical practice hours for LPN program. These hours are exclusive of laboratory hours.

Work Experience:

Five or more years of experience in clinical nursing are required. One year or more experience performing utilization review functions in a hospital or clinic setting is preferred.

Certification/Licensure-DUE UPON HIRE

-Licensed LPN able to practice within the State of MS

Mental Demands:

Exceptional oral and written skills are required to relate effectively to hospital staff, physicians, physician’s office staff, and review agencies. The individual must have the ability to type and be familiar with the rules of spelling, grammar and punctuation. The individual must have the ability to use a copier, telephone, and personal computer. Workable knowledge of DNV standards and other regulatory systems are essential. Workable knowledge of correct coding procedures, InterQual Level of Care criteria, Milliman Care Guidelines (MCG), Perspective Payment System and medical terminology is necessary. The individual must have a high energy level and be capable of handling pressure situations both mentally and physically.

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