Job Description

Job Description

Job Description

Utilization Review Analyst II Licensed Practical Nurse

Classification: Utilization Review Analyst (LPN)

Reports To: Director of Health Benefit Operations Department: Administration Compensation: Hourly/Non-Exempt

​Compensation commensurate with experience

This opportunity is located at: 25790 Commerce Drive Madison Heights, MI 48071

Under the general supervision of the Nurse Manager, the UR Analyst II Provides:

• Initial clinical evaluation and screening of UM patients.
• Ongoing objective evaluation of the important aspects of patients’ care
• Periodic review of patient records
• Identification of variations in care and provide data where applicable for use in the correction of potential over-(or under) utilization of services.
• Provides clinical support to other non-clinical staff as required.
• Perform utilization review in accordance with applicable medical policy and regulations.
• Obtain and review medical necessity and other supporting information including treatment plan requests to conduct reviews
• Validate physician’s orders to ensure appropriate and cost-effective services to patients.
• Process requests for durable medical equipment, orthotic/prosthetic, enteral nutrition and medical supplies.
• Provide clinical oversight to the case review department by reviewing, and signing-off on cases in accordance with applicable policy.
• Document review information and case notes in Northwood’s information system.
• Serve as a resource person for clinically related questions.
• Participate in the research, review and revision of medical policies on an as-needed and annual basis.
• Perform utilization follow-up contacts with patients as assigned.
• Coordinate with the clinical team to provide oversight of the utilization management program including but not limited to developing, administering and reporting on utilization management audit compliance metrics.
• Perform administrative duties; receive, log in and file a variety of documentation, reports, patient/client/provider records, interactions and other documents.
• Other duties may be assigned by management from time-to-time.
• Comply with all company information security policies and responsibilities as detailed during onboarding and annual security awareness training.

Qualifications:

• A State of Michigan Nursing license (LPN) that is active and without contingencies.
• Minimum of 2 years experience in the durable medical equipment, managed care or utilization management setting
• Excellent clinical assessment skills.
• Work with minimal supervision.
• Communicate effectively with others.
• Write clear and concise correspondence using correct grammar, punctuation and spelling.
• Work with others internally and outside the utilization management department.
• Establish priorities and work within time constraints.
• Possess strong organizational, task and prioritization skills.
• Identify medical utilization trends.
• Computer literate

*The above statements are intended to describe the general nature and level of work being performed by people assigned this classification. They are not to be construed as an exhaustive list of all duties and responsibilities of personnel so assigned.

Northwood plays an integral role in health plan benefit administration for durable medical equipment, prosthetics, orthotics and medical supplies.

Company Description

Northwood plays an integral role in health plan benefit administration for durable medical equipment, prosthetics, orthotics and medical supplies. \r\n\r\nNorthwood also serves auto and workers compensation clients and their PIP claimants.

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