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Utilization Management LPN at Adecco US, Inc.
About the position Adecco Healthcare & Life Sciences is seeking a dedicated and detail-oriented **Utilization Management LPN** to join our team in a remote capacity. This position is a two-month contract with the potential for extension or a full-time offer, providing an excellent opportunity for those looking to advance their careers in the healthcare sector. The Utilization Management LPN will play a crucial role in ensuring that prior authorization requests are reviewed and processed efficiently, adhering to both contractual and regulatory requirements. This role requires a strong understanding of medical guidelines and the ability to collaborate effectively with various departments, including Case Management. In this position, the Utilization Management LPN will be responsible for coordinating the prior authorization review process for both outpatient and inpatient service requests. This includes conducting thorough reviews of requests related to acute hospital pre-admissions, surgical and diagnostic procedures, therapies, durable medical equipment, and home health care. The LPN will utilize nationally recognized evidence-based guidelines to make informed medical determinations, ensuring that all actions align with the policies and procedures set forth by the physician group Medical Directors and UM Committees. The role also involves auditing and evaluating patient medical records to determine benefit coverage and medical necessity, as well as assisting UM Coordinators and clerical staff with clinical interpretations. The Utilization Management LPN will be expected to process denial and extension letters with appropriate language and health literacy considerations, ensuring clear communication with patients regarding the criteria used in determinations. This position is ideal for an LPN who is looking to leverage their clinical experience in a managed care environment while contributing to the overall efficiency and effectiveness of healthcare delivery. Responsibilities Ensure prior authorization requests are reviewed and completed in a timely manner. , Coordinate the prior authorization review process for outpatient and inpatient service requests. , Collaborate with the Case Management Department and other departments as needed. , Conduct accurate and thorough reviews of prior authorization requests. , Timely review of requests for acute hospital pre-admissions, surgical and diagnostic procedures, therapies, durable medical equipment, and home health care. , Make medical determinations based on evidence-based guidelines and approved policies. , Audit and evaluate patient medical records for benefit coverage and medical necessity. , Assist UM Coordinators and clerical staff with clinical interpretations and patient inquiries. , Process denial and extension letters using appropriate language and criteria. Requirements Active LPN license in the state of California. , Graduate of an accredited school of nursing required. , Bachelor's Degree in nursing or healthcare-related field or equivalent work experience. , One year of clinical experience in an acute or ambulatory patient care setting, including one year in a managed care environment. , Knowledge of Medicare, DMHC, NCQA, and MCG Guidelines. , Proficient in Microsoft Office suites. Nice-to-haves Benefits Weekly Pay , 401(k) Plan , Skills Training , Excellent medical, dental, and vision benefits , Life insurance , Short-term disability , Additional voluntary benefits , EAP program , Commuter benefits , Paid Sick Leave , Holiday pay where applicable Apply Job!
