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LPN - Case Management / Utilization Review Nurse

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Job Details
Job Order Number
Company Name
Medova Healthcare
Physical Address
Wichita, KS 67203
Job Description

We have the ability to help our members and their providers navigate a difficult healthcare system at a very challenging time of life. Our nurses are providing inpatient utilization review and case management services. While both are very administrative, they can also be very rewarding. We work in a professional office setting and do all our work via phone, email, and fax while enjoying a Monday-Friday 8-5 schedule with holidays off.

Essential Functions:
•Develop, implement and evaluate individualized patient care plans, while serving as a liaison between patients, their families and healthcare providers. Update care plans on an as-needed basis, and educate patients and their families on how to follow their care plans.
•Ensure appropriate utilization management, which focuses on helping members to obtain the right care in the right place at the right time to achieve better overall health. The evaluation is according to established criteria, guidelines, and under the provisions of an applicable health benefits plan. It includes proactive procedures and processes, such as pre-certification, concurrent planning and reviews, peer reviews, discharge planning, and clinical case appeals
•Review and analysis of clinical data for risk stratification
•Review health plan documents to determine if requested services are covered by the member’s plan
•Review networks to ensure providers and facilities are in an approved network
•Assist members in coordinating care and accessing necessary medical services while also containing costs
•Respond to inquiries from both plan members and healthcare providers
•Track data and complete logs
•Provide administrative support such as receiving and logging mail, answering calls, etc
•Abide by HIPAA regulations and other privacy policies at all times
•Maintain an exemplary attendance and tardiness record following established company guidelines
•Demonstrate ability to work well with other departments and all Medova staff members
•Complete other tasks, as assigned

•Technical Capacity
•Customer Service
•Problem solving

Required Education and Experience:
•Active LPN license
•Minimum of 3 years of broad clinical experience

Preferred Education and Experience:
•Medical coding or claims knowledge
•Oncology experience
•Experience in case management

Computer Skills:
•Microsoft Outlook
•Microsoft Word and Excel
•Data Entry

Position Type and Expected Hours of Work:
•Monday-Thursday 8am-5pm; Friday 8am-4pm

Work Environment:
•Professional office environment
•Standard office equipment such as computer, phone, postage machine, and copier/scanner/fax
•Tobacco free

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