Licensed Vocational Nurse (LVN) - 4LOCS(NY)

Licensed Vocational Nurse (LVN)

Responsibilities:

• Responsible for providing timely referral determination by accurate:
• Usage of the Milliman Care Guidelines
• Identification of referrals to the medical director for review
• Appropriate letter language and coding (denials, deferrals, modifications)
• Appropriate selection of the preferred and contracted providers
• Proper identification of eligibility and health plan benefits
• Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
• Responsible for maintaining compliance in turnaround time requirements as mandated by the ICE TAT Standards
• Responsible for working closely with manager to address issues and delays that can cause a failure to meet or maintain compliance.
• Meets or exceeds production and quality metrics.
• Work directly with the provider(s) and plan Medical Director to facilitate quality service to the member and provider.
• Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management).
• Attend all mandatory meetings and training.
• Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
• Collaborates, educates and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria.
• All other job - related duties as it relates to the job function or as delegated by the management team.