LPN - Utilization & Disease Management
Role expectations for Utilization Management Nurse includes assessing, organizing, implementing and evaluating the care and utilization across the continuum, to enhance quality patient care while simultaneously promoting cost effective resource utilization. This role performs utilization management, discharge planning, and screens for case management referrals. The Nurse assesses the needs of patients/clients and their significant others, while being aware of outcomes, costs, and processes. The nurse combines the roles of clinician and educator to accomplish desired clinical outcomes.
RESPONSIBILITIES:
- Knowledge of prospective payment systems, managed care vendor’s policies, infection control surveillance,
patient care, disease processes, discharge planning and continuum of services offered with QCP and externally.
- Knowledge of URAC Standards, other regulatory bodies and of QCP activities and services related to the
comprehensive performance of duties.
- Ability to compile a clinical review and knowledge and ability to utilize electronic documentation systems.
- Excellent verbal and organizational skills to facilitate the case management process and ensure patients and
customers are served promptly and with respect.
- Clear documentation of medical necessity for all services.
- Complete follow through for disposition of cases for Medical Director review, potential quality chart reviews,
stop-loss notifications, and case management referrals.
- Carries out job requirements as delegated by and with the supervision of a registered nurse and/or the QCP
medical director. Other duties as assigned.
REQUIRED QUALIFICATIONS:
- Current unrestricted licensure or certification to practice a health or human services discipline in a state or
Territory of the United States.
- Two years full time equivalent providing direct clinical care to the consumer.
- Licensed practical nursing licensure or certification in specialty are preferred.
- Must have a valid driver’s license and reliable transportation.
