MD Anderson Cancer Center Utilization Review Specialist - LVN or LPN in Houston, Texas

The University of Texas MD Anderson Cancer Center in Houston is one of the world's most respected centers focused on cancer patient care, research, education and prevention. It was named the nation's No. 1 hospital for cancer care in U.S. News & World Report's 2016 rankings. It is one of only 45 comprehensive cancer centers designated by the National Cancer Institute.

Ideal candidate will be a Licensed Vocational Nurse (LVN or LPN) and will have four years of clinical experience, to include two years' experience in utilization review or case management.

SALARY RANGE $49,600 - $62,000 - $74,400

SUMMARY

Utilize skilled intervention and clinical best practice to concurrently screen admission, concurrent and discharge review with payors in collaboration with Case Management for utilization issues.

KEY FUNCTIONS

Building Relationships: Establish and maintain professional relationships with case managers, members of the multidisciplinary team, payors and other customers.

Utilization Review: Responsible for daily management of working task list of assigned utilization reviews. Perform utilization review on all patients as appropriate utilizing MCG (Formerly Milliman Care Guidelines) according to departmental guidelines. Reviews all available data sources to provide utilization review (admission, continued stay, retrospective and readmission review, management of observation status). Responsible for completion of all commercial and non-commercial utilization reviews, as assigned. Obtains authorization for length of stay from insurance payor. Utilizes EHR pre-certification and authorization screens.

Regulatory: Working knowledge of regulations, standards and legislation (Medicare, Medicaid, Managed Care and other insurance payors) related to the continuum of care and patient transition to alternate levels of care.

Documentation/Communication - Responsible for providing payor with accurate clinical documentation. Ensures required justification and documentation is provided to payors. Responds to payor inquiries by fax or phone. Must follow-up with payor if response is not received within 2 business days to verify continued authorization of hospital stay. Responsible for timely follow-up with payor when patient is discharged to complete case closure and verify authorization of all dates of service. Identifies, documents and notifies payor of changes in the level of care. Communicates with the Financial Clearance Center (FCC) to seek clarification and/or completion of authorization precertification process. Communicates with Case Manager and/or leadership when additional clinical information, payor requests and/or denials are received. Communicates, collaborates and assists the assigned case manager to facilitate the appeal process for insurance payor denials. Work with payor to clarify number of days authorized and documents in the EHR. Document all communication/authorizations for services in the EHR according to departmental guidelines.

EDUCATION

Required: Completion of an approved school of vocational practical nursing.

EXPERIENCE

Required: Four years of clinical experience, to include two years' experience in utilization review or case management.

LICENSE/CERTIFICATIONS

Required: Licensed Vocational Nurse (LVN) by the Texas Board of Nursing.

It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. http://www.mdanderson.org/about-us/legal-and-policy/legal-statements/eeo-affirmative-action.html