At Vantage Health Plan we specialize in taking care of people: our members, our patients, and our employees. We offer competitive salaries and great benefits! Benefits include: Health, Dental, Life, Accidental Death and Dismemberment, Long Term Disability, Paid Time Off, and 401(k).
** Work from home opportunity for Louisiana Residents**
Job Summary: The Utilization Management Program of Vantage Health Plan assures the delivery of medically necessary, quality patient care through appropriate utilization of resources in a cost effective and timely manner. The Medical Management Nurse is an intricate part of this program by utilizing Vantage’s authorization system to review and approve services based upon Standardized Criteria, Health Plan Medical Policy and Clinical Guidelines and the local delivery systems. Each request for service is authorized in accordance with the member’s health plan benefits and mandates from regulatory agencies. The remote RN will have the same essential duties and responsibilities as the on-site RN.
Essential Duties & Responsibilities:
• Performs initial intake, review and notification of decisions for authorization of outpatient services. These requests are initiated via phone, fax and/or email and include all of Vantage’s lines of business
• Enters appropriate information for each authorization including diagnosis codes, procedure codes, and request types into Vantage’s authorization system
• Obtains clinical information necessary to perform a thorough review of the request for services
• Applies standardized criteria to each request and may approve requests for services, if appropriate
• Works with provider’s office staff, physicians, and members to coordinate approval of services or provides detailed explanations of reasons for denial of services or alternate services recommended
• Performs retrospective reviews, as appropriate, for authorization of procedures and services
• Forwards all requests to Vantage’s Medical Directors when criteria for approval is not met
• May be assigned extracurricular activities, which could include underwriting, subrogation, reimbursement authorizations, maintaining provider portals, claims processing queues and special projects
• Other duties as assigned
Knowledge, Skills, and Abilities:
• Graduate of an accredited school of Nursing with current license to practice as an RN in the State of Louisiana
• Exceptional interpersonal, verbal, and written communication skills
• Previous experience in Utilization Review, case management, and/or medical underwriting.
• Customer service-oriented attitude/behavior
• Ability to work with limited supervision and to make decisions based on established policies and procedures
• Works under general supervision of the Outpatient RN Coordinators and Director of Medical Management
• Overtime will be occasionally required
• Travel will be required every 2 months minimum (at the cost of Vantage Health Plan)
• Must be virtually present at every staff meeting
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit, use hands and fingers, handle or feel, reach with hands and arms, and talk or hear. The employee is frequently required to stand and walk. The employee must regularly lift and/or move up to 10 pounds and occasionally lift and/or move up to 50 pounds.