Licensed Practical Nurse Utilization - Other General Services - Mamou, LA

Summary

The LPN Utilization Review effectively communicates with internal and external professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors, to obtain approved certification for services. They critically think for appropriateness of care provided to the patients and competently utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services “CMS” Inpatient List). The LPN Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.

Responsibilities

Under the supervision of a Registered Nurse

• Uses a directed scope of practice to perform focused reviews of clinical documentation and applies medical necessity criteria to determine appropriate level of care
• Performs focused reviews utilizing specialized nursing judgement and skill
• Resource/Utilization Management appropriateness: Assess assigned patient population for medical necessity, level of care and appropriateness of setting and services. Utilizes MCG/InterQual Care Guidelines and/or health system approved tools to track impact and variance
• Collaborates with physician and treatment team to obtain documentation needed to support proposed level of care
• Communicates effectively with members of the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses
• Demonstrates and maintains current knowledge of regulation relative to work process for compliance, i.e. IMM, Code 44
• Utilize steps and procedures to review documentation and understand the discharge planning process
• Coordinate certification of services with the appropriate payor
• Participate in the evaluation of care administered by the interdisciplinary health care team
• Report data to assist in the identification of potential documented problems to assist with the formulation of goals/outcomes
• Follows the CHRISTUS Guidelines related the Health Insurance Portability and Accountability ACT (HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
• Attend scheduled departmental staff meetings and/or interdepartmental meetings as appropriate
• Demonstrates positive customer relationship techniques (customers include patient, physicians, other health care team members, payers, etc.) Uses Acknowledge, Introduce, Duration, Explanation, Thank (AIDET) appropriately
• Proactively refers cases to the physician advisor for medical necessity reviews, peer-to-peer reviews, and denial avoidance
• Possesses and demonstrates technology literacy and the ability to work in multiple technology systems
• Acts as a catalyst for change in the organization; responds to change with flexibility and adaptability; demonstrates the ability to work together for change.
• Translates strategies into action steps; monitors progress and achieves results.
• Demonstrates the confidence, drive and ability to face and overcome challenges and obstacles to achieve organizational goals.
• Demonstrates competence to perform assigned responsibilities in a manner that meets the population-specific and developmental needs of patients served by the department
• Negotiating skills which support the ability to interact with physicians, nursing staff, administrative staff, discharge planners, and payers
• Excellent verbal and written communication skills, Knowledge of clinical protocol, normative data and health benefit plans, particularly coverage and limitation clauses
• Must adjust to frequently changing workloads and frequent interruptions
• May be asked to work overtime or call with little or no notice
• May be asked to travel to other facilities
• Demonstrates adherence to the CORE values of CHRISTUS.
• Other duties as assigned

Requirements

Experience

• Knowledge of scope and role of the Licensed Practical Nurse, Nursing Assistant, Mental Health Tech and Unit Clerk.

Licenses, Registrations or Certifications

• Current LPN License Licensed Practical Nurse within the state of Louisiana
• Current BLS
• De-Esculation Certification completed within 90 days of employment and recertified annually.

Work Schedule:

8AM - 5PM Monday-Friday

Work Type:

Full Time