About the job
Job Title: Case Management Analyst ( LPN AND LVN LICENSE)
Duration: 6+ Month
Pay : $19
Schedule Notes:
M-F, 8AM-5PM CST
Training will be the same schedule for the first 3 weeks
Weekend rotation – required to work Sat & Sun 1x every 6 weeks
Responsibilities
This position is 100% remote and candidates can be sourced from across the US as long as they’re able to support the CST schedule.
Candidates submitted cannot have any time off during the first 6 weeks – do not submit candidates that have pre-planned time off during this timeframe.
Candidates must have a quiet and private working environment.
Candidates must have a reliable, high-speed internet connection.
Candidates must have a hard-wired internet connection to connect into the equipment – WiFi connection will not suffice.
Responsible for collaborating with healthcare providers, members, and business partners, to optimize member benefits, evaluate medical necessity and promote effective use of resources. Medical necessity reviews may include: inpatient admissions, outpatient services, surgical and diagnostic procedures, home health, durable medical equipment and out of network services. Conduct reviews in compliance with medical policy, member eligibility, benefits, and contracts.
Essential Duties and Responsibilities:
Responsible for the effective and sufficient support of all Utilization Management activities to include review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies and compliance guidelines.
Uses an established set of criteria to evaluates and authorize the medical necessity of services.
Provide notification of decisions in accordance with compliance guidelines.
Coordinate with Medical Directors when services do not meet criteria or require additional review.
Participation in staff meetings, regular trainings and other collaborative meetings as appropriate.
Works with management team to achieve operational objectives and financial goals.
Supports teams across UM Department as needed.
Active participation and completion of all required trainings.
Maintain Required Licensures
Adherence to regulatory and departmental timeframes for review of requests
Meet/exceed department Turn Around time, daily established productivity goals, and service levels
Proficient knowledge of policies and procedures, Medicare, HIPPA and NCQA standards;
Professional demeanor and the ability to work effectively within a team or independently;
Flexible with the ability to shift priorities when required
Holiday rotation (2 holidays per year)
Weekend rotation
Other duties as required
Qualifications:
Current unrestricted LPN/LVN license – Multi-State License Preferred
REQUIRED: Current, unrestricted LPN/LVN License in the state currently residing
Minimum of 1 year experience in a regulated environment preferred
Minimum of 2+ years clinical experience required
Strong customer orientation
Strong organizational, planning, and communication skills
Working knowledge of insurance industry, medical coding (CPT/HCPCS/ICD-10), and overall claims process a plus
Knowledge of National Coverage Determinations, Local Coverage Determinations and MCG criteria are a plus.
Excellent time management skills
Proficient in basic computer skills
Knowledge, Skills, Abilities Required:
Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member
Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments
Able to work in a dynamic, fast-paced team environment and to promote team concepts
Excellent typing and computer skills.
Substantial knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word.
Previous experience working in a remote environment
Education:
HS Diploma/GED & LVN/LPN License