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Job Title
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LPN/LVN Utilization Review I 42576
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Date
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2009-11-02 |
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Company
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Wellpoint
(View All Jobs)
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Location
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Indianapolis,
IN
46298
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Category
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Healthcare
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Posted by
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abishop |
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Job Description
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Description
At WellPoint, we are dedicated to improving the lives of the people we serve and the health of our communities.
WellPoint strives toprovide the best health care value for our customers.
Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment.
Primary duties may include, but are not limited to: Conducts pre-certification, concurrent (if not associated with CM or DM triage), retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.
Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.
Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.
Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.
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LPN/LVN Utilization Review I 42576
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