UR/Precertification LPN/LVN

    • Job Tracking ID: 512935-584774
    • Job Location: Meridian, ID
    • Job Level: Mid Career (2+ years)
    • Level of Education: 2 year degree
    • Job Type: Full-Time/Regular
    • Date Updated: August 01, 2017
    • Years of Experience: 2 - 5 Years
    • Starting Date: August 28, 2017
    • Salary Type:: Salary
    • Rate:: Starts at $44,000 (DOE)
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Job Description:


Job Summary


The Utilization Review/Precertification LPN/LVN conducts pre-certification, inpatient, retrospective, and appropriateness of treatment setting reviews by utilizing clinical guidelines and medical policies in compliance with department guidelines and consistent with the member’s plan benefit. Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.


Key Result Areas


  • Conducts utilization review/precertification services including prospective, concurrent, medical necessity and retrospective reviews.
  • Determines medical necessity and appropriateness of requested inpatient and outpatient services through review of clinical information and application of the specific clinical criteria guidelines, medical policies and plan benefit.
  • Provides authorization of services, or forwards requests to physician/Medical Advisor for determination.

  • May access and consult with peer clinical reviewers, Medical Advisor and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
  • Facilitates communication with health care providers involved with the care of the member to obtain complete and accurate information, to advise of determinations, and to educate regarding medical management processes.
  • Facilitates appeal and external review requests in coordination with the Appeals department.
  • Communicates with providers and other departments to facilitate care, referrals, transitions of care, and discharge planning.
  • Identifies solutions to non-standard requests and problems.
  • Maintains concise documentation and confidentiality of records and information.
  • Attends on-site weekly company/team meetings and monthly staff meetings.
  • Performs all duties within the scope of licensure.
  • After six months of demonstrated efficiency in position, working from home may be possible.



Experience and Skills:

Minimum Qualifications


·         Current unrestricted LPN/LVN license.

·         Graduated from accredited School of Nursing.

  • 2 years of clinical or utilization review experience.

  • Certification in Utilization Management or Case Management preferred.

  • Knowledge of UR/Case Management functions, self-funded insurance plans, networks and coding.

  • Type 45 words per minute and intermediate level experience in Microsoft Word, Excel, Outlook, and Power Point.

  • Strong interpersonal/communication (verbal and written) skills and the ability to work effectively with a diverse patient population.

  • Ability to work independently under general instruction and with a team.

  • Ability to maintain confidentiality, work efficiently in fast paced environment, prioritize tasks, and meet tight deadlines.

  • Completes all projects in a timely and accurate manner.

  • Ability to efficiently and effectively perform the Essential Key Result Areas with or without a reasonable accommodation without posing a direct safety threat to others or self.

  • Protect and enhance the Core Purpose and the Core Values of the AmeriBen/IEC Group.