Utilization Management Director jobs in North Carolina

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The utilization management coordinator LPN role is to ensure that health care services are administered with quality, drug cost efficiency, and compliant with payer policy. By continuously reviewing and auditing patient treatment files, the utilization nurse will ensure that patients won't receive treatment/procedures without pre-authorization from payer obtained. Communicating to provider payer position specific to medical necessity.

Job Duties and Responsibilities:

* Concurrent review of patient's clinical information for maintaining active pre-authorization and communication with payer plans for treatment/procedures.

* Ongoing review of precertification requests for medical necessity, ensuring active authorization on file prior to treatment delivery

* Monitor the activities of clinical and non-clinical staff supporting patient treatments requiring pre-authorization, and approving treatment delivery.

* Employ effective use of knowledge, critical thinking, and skills to:

o Advocate quality care and enhanced quality of treatment experience with provider, aligning with patient payer plan requirements.

o Monitor new treatment activities and subsequent changes impacting pre-authorization on file.

o Communicate to provider any payer-imposed policies impacting treatment delivery.

* Maintain accurate records of all patient pre-authorization activities.

* Work in an intensive, fast-paced environment with minimal supervision

* Ability to stay organized and interact well with others in any situation

* Provide daily updates to physician, or other healthcare providers supporting patients for pre-authorization status.

* Discuss payer exceptions with provider, ie. Payer formulary, pharmacy substitution allowing provider to review any necessary changes imposed by the payer

1. Education:

• Associates Degree required.

2. Certifications/Licenses:

• State Licensure as a Licensed Practice Nurse (LPN)

• Utilization Management or Case Management certification preferred

3. Previous Experience:

• Two years LPN experience; physicians practice; oncology preferred.

• Two years experience in utilization management and obtaining insurance authorizations in a medical setting.

• Relevant clerical or case management work in a medical office setting.

• Must have excellent interpersonal and communication skills, be very detail-oriented and a self-starter.

4. Core Capabilities:

• Analysis & Critical Thinking: Critical thinking skills including solid problem solving, analysis, decision-making, planning, time management and organizational skills. Must be detailed oriented with the ability to exercise independent judgment.

• Interpersonal Effectiveness: Developed interpersonal skills, emotional intelligence, diplomacy, tact, conflict management, delegation skills, and diversity awareness. Ability to work effectively with sensitive and confidential material and sometimes emotionally charged matters.

• Communication Skills: Good command of the English language. Second language is an asset but not required. Effective communication skills (oral, written, presentation), is an active listener, and effectively provides balanced feedback.

• Customer Service & Organizational Awareness: Strong customer focus. Ability to build an engaging culture of quality, performance effectiveness and operational excellence through best practices, strong business and political acumen, collaboration and partnerships, as well as a positive employee, physician and community relations.

• Self-Management: Effectively manages own time, conflicting priorities, self, stress, and professional development. Self-motivated and self-starter with ability work independently with limited supervision. Ability to work remotely effectively as required.

• Must be able to work effectively in a fast-paced, multi-site environment with demonstrated ability to juggle competing priorities and demands from a variety of stakeholders and sites.

• Computer Skills:

• Proficiency in Microsoft Office: Word, Excel, PowerPoint, and Outlook required.

5. Travel : <25%

6. Standard Core Workdays/Hours (specify weekends and call requirements): Monday to Friday 8:00 AM - 5:00 PM.

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