UTILIZATION MANAGEMENT COORDINATOR / LPN Nurse
Chesterfield Companies is a third-party administrator for health claims located in Uniontown, Ohio. We are looking to add to our staff. Regular work hours will be from 8:00 am – 5:00 pm, Monday through Friday.
This position ensures coordination of quality health care services by identifying appropriate services and resources are being utilized in a timely and cost effective manner throughout the continuum of care.
Summary of Job Responsibilities:
- The Utilization Management Coordinator is an expert in the areas of utilization management, continuum of care planning, benefit interpretation, disease management, and insurance industry regulations.
- Receive clinical information on an individual via fax or phone and apply it to existing criteria guidelines for determination of a recommended treatment plan.
- Determine if received clinical information is adequate and appropriate for requested treatment plan. Completes reviews within designated URAC timetable.
- Perform care management activities as needed. Is familiar with and will access all clinical criteria guidelines before determining need for secondary review.
- Monitor changes in level of care (LOC) and appropriateness of changes.
- Participate in discharge planning.
- Reviews for medical necessity of durable medical equipment
- Prioritize phones, pre-certifications and follow through for pre-certifications.
- Completes appeal determinations received from Physician review.
- Responsible for appropriate application of Medical Policy and criteria.
- A representative of Healthcare Management Services across the corporation.
- Valid Ohio Licensed Practical Nursing License or Licensed Clinical Social Worker - REQUIRED
- 2-3 years experience in Clinical Nursing
Additional relevant knowledge and/or skills and/or work experience:
- Excellent written and verbal communication skills.
- Ability to interact with all levels of the organization.
- Ability to interact with external customers and providers.
- Ability to analyze data, measure outcomes and develop action plans.
- Highly effective interpersonal skills.
- Recognized as a clinical nursing expert.
- Ability to intervene in crisis situations and multi-task.
- Excellent computer and software knowledge and skills.
What is in it for you:
Join an established company that appreciates its people
Excellent benefits package
Medical insurance, Dental insurance, Vision insurance