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Wexford Health’s Quality Management and Corporate Compliance department is made up of certified clinical auditors, licensed nurses and other industry experts who focus on quality improvement/assurance, accreditation and clinical training.

Utilization Management Nurse Coordinator - LPN Job



Job Number: 80926516566

Location: Pittsburgh, PA

Date Posted: 11-28-2017

 

Wexford Health Sources, one of the nation's leading innovative correctional health care companies, provides clients with experienced management and technologically advanced services, combined with programs that control costs while ensuring quality.  For nearly two decades, Wexford Health has consistently delivered proven staffing expertise and a full range of medical, behavioral health, pharmacy, utilization management, provider contracting, claims processing, and quality management services.

At Wexford Health our philosophy is that health care should not be considered a luxury for anyone.  We simply care for those in need and the corrections environment is our venue.

Wexford Health has an exceptional opportunity for a Utilization Management Nurse Coordinator (LPN) to join our team of healthcare professionals at our Corporate Office in Greentree, PA.

We’re proud to offer a competitive benefits package including:

  • Annual review with performance increase
  • Generous paid-time off program that combines vacation and sick leave
  • Paid holidays
  • Comprehensive health insurance through Blue Cross Blue Shield
  • Dental and Vision insurance
  • 401(k) retirement savings plan
  • Company-paid short-term disability
  • Healthcare and dependent care spending account

POSITION SUMMARY

 Monitors and evaluates the medical necessity, appropriateness, and efficient use of health care services; works closely with the Utilization Management (UM) RNs and correctional facility staff and providers to ensure timely, cost-effective care at the level most appropriate to the inmate; provides reports and recommendations for improved utilization of resources and completion of authorized services.

DUTIES/RESPONSIBILITIES

DAILY

  1. Reviews referral requests, communicates with providers and correctional facility staff for referral clarification and accuracy Enters referral requests and enters or updates Wexcare/Referral entry system
  2. Provides correctional facilities with authorizations/reference numbers
  3. Reviews history of consultations utilizing InterQual and Milliman (MCG) Healthcare Guidelines and current medical literature Helps to identify quality of care or potential risk management issues
  4. Updates computer system with actual dates of service  
  5. Notifies UM physicians and nurses of scheduling conflicts
  6. Contacts individual facilities for scheduling issues
  7. Identifies areas for concern and communicates to Manager of UM

WEEKLY

  1. Reports compliance on the weekly Service Completion Log
  2. Reviews weekly Service Completion Logs and identifies areas for improvement/compliance
  3. Provides weekly reports to regional operators concerning outstanding appointments

MONTHLY

  1. Provides an overview of service completion statistics
  2. Forwards referral statistics to regional operators (state specific) and Manager of UM

OTHER DUTIES AS REQUIRED

  1. Assists callers with questions and refers to UM RN or Manager
  2. Review of infirmary, inpatient and outpatient cases as needed
  3. Reviews Reports to monitor appropriateness and accuracy of the referral process
  4. Follows referral review guidelines to assure accurate completion
  5. Reviews deferred claims and provides resolution as needed
  6. Maintains open interdepartmental communication with Accounts Payable, Risk Management and Operations
  7. Prepares statistical reports as instructed by the UM Manager
  8. Assists with orientation of new UM staff
  9. Educates correctional facility staff and physicians regarding referral and scheduling compliance
  10. Works on special projects as assigned
  11. Participates in UM Staff Meetings

The duties and responsibilities outlined herein are for payroll purposes only; employees may be assigned other duties as required.

ENVIRONMENTAL CONDITIONS

Standard office environment in a Corporate office setting which includes daily interfacing with Administration and health care personnel.


 

TRAVEL: None

LICENSING: Requires current, LPN nursing license in state of assignment

CERTIFICATION: Current CPR certification.

EDUCATION:

  • Graduate of an accredited Nursing Program
  • Wexford Health Sources, Inc. encourages educational training to improve or update clinical knowledge, etc.

PREFERRED EXPERIENCE:

  • Preferred 2 years’ experience as a LPN in a health care setting but not required.
  • Utilization management/case management experience preferred but not required.
  • Knowledge of ICD-9 and CPT codes preferred but not required.
  • Knowledge of word processing and spreadsheet programs.

EOE/M/F/D/V


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