LPN Case Manager Clinical Authorization

LPN Case Manager

LPN Case Manager provides support for the Care Management Department by coordinating and promoting comprehensive quality, cost-effective care.

Primary Duties and Responsibilities

• Assists in the identification of potential Case Management candidates through clinical review selected diagnoses etc. and makes appropriate referrals.
• Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
• Demonstrates behavior consistent with Med Star Health mission vision goals objectives and patient care philosophy.
• Identifies and reports potential coordination of benefits subrogation third party liability workers compensation cases etc. Identifies quality risk or utilization issues to appropriate Med Star personnel.
• Initiates contact with providers to obtain clinical information to facilitate care or pending pre-certification requests. Interacts with assigned disease management populations of limited volume. Interaction is designed to improve patient access to care and education regarding the disease and support services.
• Maintains current knowledge of Med Star Family Choice benefits and enrollment issues in order to accurately coordinate services.
• Maintains expertise in general benefit management and serves as a resource for Med Star Family Choice members physicians and staff for benefit interpretation and coordination.
• Maintains timely and accurate documentation in the IS System per Case Management policy.
• Participates in meetings work groups etc. as assigned.
• Processes pre-authorizations for medical necessity LOC covered benefits and participation of the provider at the discretion of the guidelines and Medical Reviewer.
• Sends reviews to Medical Reviewer as appropriate. Coordinates review decisions and notifications per policy.

Minimal Qualifications

• Valid LPN License in the State of Maryland. required

Experience

• 1-2 years Utilization review experience required and
• 3-4 years Diverse clinical experience required

Licenses and Certifications

• LPN
  - Licensed Practical Nurse
  - State Licensure Valid LPN license in the State of Maryland or District of Columbia. Upon Hire required

Knowledge Skills and Abilities

• Knowledge of current trends in healthcare delivery and utilization review criteria.
• Ability to use computer to enter and retrieve data.
• Ability to create edit and analyze (Word Excel and PowerPoint) preferred

This position has a hiring range of USD $32.71 - USD $53.49 /Hr.