Utilization Review - LPN OLL

The Utilization Review Nurse performs Utilization Review on all patients to ensure appropriate resource utilization, authorization of hospitalization and tracking of avoidable days.  Relies on education, some experience and judgment to accomplish job.  Works under general supervision. Creativity and some latitude is expected to complete responsibilities.

1. Evaluation and Analysis: This will have been satisfactorily performed when…
   1. Patient cases are reviewed for medical necessity and Intensity Service/Severity of Illness to ensure patient is admitted to the appropriate status within 2 days of admission.
   2. Appropriate level of care is determined, and rollovers sent as evidenced by roll over sheets and no denials due to inappropriate status.
   3. Clinical documentation is reviewed to ensure that services are being provided appropriately and documentation meets agency and regulatory requirements at all times as evidenced by no denials.
   4. Current treatment plans are reviewed daily to evaluate appropriateness of services and progress toward treatment goals as evidenced by documentation and no denials. 
2. Partnership and Collaboration: This will have been satisfactorily performed when…
   1. A working knowledge of Managed Care Contracts, third party payor criteria and InterQual have been demonstrated as evidenced by annual competency check list.
   2. Documentation of all utilization review information is complete in AS 400 as evidenced by reports.
   3. Positive, competent and respectful interaction with patients, families, caregivers, staff, co-workers, physicians, and community agencies is given at all times as evidenced by no written or verbal complaints.
   4. Business Office is immediately notified when category changes occur as evidenced by review of roll over sheets.
   5.  Physicians are notified of need for additional documentation or adjustments to treatment plan to promote continuum of care as evidenced by documentation and no denials.
   6. Confidentiality is maintained at all times when dealing with patients, staff or physician issues as evidenced by no verbal or written complaints.
3. Quality: This will have been satisfactorily performed when…
   1. Documentation of interventions are accurately transcribed in the Account Based notes as evidenced in documentation.
   2. No denials due to inappropriate reviews or follow-up are received as evidenced by documentation and no denials.
   3. Available notes for review are clear, concise, and contain evidence of action taken as evidenced by documentation.
   4. All potential denials are reviewed followed by appropriate intervention as evidenced by documentation.
   5. Prompt notification of CM Manager or Director of possible quality or physician issues as evidenced by direct observation.
4. Other Duties as Assigned: This will have been satisfactorily performed when…
   1. Other duties as assigned are completed.

Experience - 3 years acute care LPN experience
Education - Graduate from Accredited LPN Program
Special Skills - Excellent communication and organizational skills.
Licensure - Current Louisiana License as an LPN