Utilization Management Nurse Reviewer (LPN) Part-time (remote FL residents only)

Utilization Management Nurse Reviewer (LPN) (Part-time up to 24 hours a week) (remote/Work from home position for FL residents only) Currently seeking a (PART-TIME) FL licensed LPN for Utilization Management/ Review for a great opportunity working remotely (FROM HOME) at a dynamic healthcare organization based in Miami, FL area. The ideal candidate will possess 3 years of experience managing the treatment plan and utilization for members receiving Home Health Care / Infusion Services. JOB SUMMARY: Manages the treatment plan and utilization for all members receiving Home Health Care / Infusion Services and Durable medical equipment and supplies. Conducts the review process for those requests that appear not to be medically necessary; facilitates, coordinates and evaluates the ongoing care of a specific caseload of patients to collaborate with physicians, the patient and the family to assure cost-effective, high quality, appropriate home care for the patient during the entire episode of illness and for post discharge services and to monitor and evaluate patient outcomes, including self-management.

Duties of the Home Health Case Manager include but are not limited to: Receive updated orders and medical information from all referral sources, i.e. Hospitals, Physician’s offices, Skilled Nursing Facilities, Rehabilitation Centers, Health Plans, PHOs, CM Departments, Home Health Agencies and others. Perform clinical review, to ensure that pre-established medical necessity/appropriateness criteria are met. Refer reviews that do not meet coverage criteria to Medical Director and/or Health Plan. Review and evaluates home health admission for clinical appropriateness of the continued care. Identifies and engages patients in appropriate care. Develop coordinated, collaborative care plans with all involved providers. Perform reviews telephonically using the member’s medical records, discussion with the member’s physician and/or discussion with Home health agency staff. Facilitate timely discharges and transfers based on individual needs and care requirements Educate patients to help them understand their health choices and assist them in making informed decisions about their health care. Serve as information resource and liaison to patients, health care professionals, facilities, health plan representatives, care givers, agencies and family members. Monitor cost-effective use of resources. Monitor health care service delivery and utilization according to the plan of care Provide authorizations and notifications in a timely manner. Maintain/update active patient list Document and resolve first line patient treatment plan. Prepare concise clinically based rationales that support clinical criteria such as: CMS, Medicaid, Health Plan Benefits, and InterQual Maintain a working knowledge of, and adheres to applicable federal/state regulations including but not limited to, laws related to patient confidentiality, release of information, and HIPAA Input the pertinent information and authorization into the appropriate software Maintain files. Participate in department meetings and in-services