Full Time Optum Utilization Review Jobs in Rochester, NY

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LTSS Reviewer - LPN

Summary

Description

Every care plan tells a story about someone's ability to stay safely at home. As our next LTSS Utilization Review Nurse (LPN), you'll be the clinical eye that makes sure that story adds up - turning physician orders and assessments into the right services, the right hours, and the right outcome for the members who count on us  most. If you find real satisfaction in getting the details right because a person's independence depends on it, we'd love to meet you.
Looking for meaningful work with an Organization that values you? It's here! Join our team of dedicated, caring professionals in our passionate pursuit of improved access and quality of healthcare for underserved populations.

For over 50 years, Elm & Oak Health, a not-for-profit health care services organization, has been focused on improving the health status of individuals and families who are recipients of government sponsored health insurance. Elm & Oak Health is one of the largest Care Management Agencies serving 28 counties and over 3000 members with an outstanding reputation for excellence throughout our service area! We've earned that reputation by providing quality care management focused on compassion, empowerment, and teamwork. Our award-winning work culture is built on these same principles! When you join our team, you can expect to reap the intrinsic rewards of serving others while enjoying flexible work arrangements, competitive pay, superior benefits, and a supportive, inclusive culture!

We are currently looking for an experienced and qualified, full time LTSS Reviewer, LPN for Utilization Management. We offer competitive pay, flexible schedules and great benefits. If you are passionate about helping individuals and working one on one with them, this might be the right fit for you. Our mission encompasses compassion, empowerment and teamwork. We believe if we are supportive and compassionate to our employees, it will spill over to our members.

LTSS Reviewer - LPN
Grade 207
This is a full time position, Monday - Friday, working from home. The incumbent must have a valid, unrestricted, NYS LPN license.
The minimum and maximum annual salary that Elm & Oak Health believes in good faith to be accurate for this position at the time of this posting are $46,948 - $57,380. In addition to your salary, Elm & Oak Health offers a comprehensive benefits package (all benefits are subject to eligibility requirements) and non-monetary perks. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

POSITION SUMMARY

Provides utilization review for LTSS services including physician orders, UAS completeness, Time Task Tool creation and coordination of review determination with appropriate providers and member notification.

Research and respond to provider vendor complaints and appeals for LTSS services.

POSITION HAS DIRECT REPORTS: No

ESSENTIAL JOB DUTIES/FUNCTIONS

% of Time

Essential Function

100%

Principal Accountabilities

• Under the supervision of a Registered Nurse and in coordination with the LTSS Program Coordinator, performs utilization review activities for the LTSS program including physician orders, UAS documentation, creation of the time task tool to determine appropriate services and hours based on NYS DOH guidelines, UM policies and procedures. LTSS utilization reviews involve reviewing and approving the medical necessity of proposed services, and referring cases that may not meet clinical guidelines to a Medical Director for further consideration. In accordance with applicable law, all medical necessity denials must be made by a Medical Director.
• Ensures time frames are met on all activity
• Review LTTS plans of care with providers, facilities and members based on level of service required.
• Maintains current and accurate records for all service requests.
• Assists RN to ensure NCQA, HEDIS and DOH requirements relative to patient care are met or exceeded across all lines of business.
• Maintains all confidentiality policies and procedures according to HIPAA regulations.
• In conjunction with the manager, identify and develop clinically appropriate cost effective programs to improve quality of care for members receiving clinical services through Monroe Plan.
• Assure improved health care outcomes by identifying and referring to case management department, members who may benefit from case management services.

• Assists Informatics Department in development and support of informatics systems: .
• Research and respond to both internal and external provider vendor complaints and appeals.

Total must equal 100% - essential functions should be completed at least 10% of the time

OTHER FUNCTIONS AND RESPONSIBILITIES

• Participate in new Elm & Oak Health staff orientation.
• Assist other members of the Clinical Services team as needed.
• Performs other duties as assigned.

MINIMUM REQUIREMENTS/LICENSES/CERTIFICATIONS

Must possess a current, unrestricted NYS LPN licensure. Ability to demonstrate excellent communication skills both oral and written, as well as, strong interpersonal skills. Ability to work independently and have an understanding of utilization management, treatment planning and discharge planning. Strong organizational skills. Excellent typing and computer skills required. Strong organizational skills.   PREFERRED QUALIFICATIONS

• A minimum of two years experience in general medicine/surgery/home care preferred.
• Prior Utilization Review experiences a plus.

PHI MINIMUM NECESSARY USE: This staff position PHI access will be determined based on Minimum Necessary standards. The Minimum Necessary Grid can be found on the Human Resources and Compliance Web pages.

This job description is only a summary of the typical functions of the job, not an exhaustive or comprehensive list of all possible job responsibilities, tasks and duties. Additional responsibilities, tasks and duties may be assigned as necessary.

Elm & Oak Health is an Equal Opportunity Employer.

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