Um Nurse Reviewer (Lpn)

Who we are: 

IHCS provides an Integrated Delivery System in the home setting, which includes, DME, Respiratory, Home Health and Home Infusion services. IHCS has a select network of Medicare and/or Medicaid Certified and Accredited providers to respond to the needs of our patients – 24/7. We operate with the sole intent of providing the highest quality in-home care services that improve and enhance the daily living for our patients, where our patients are #1 

Our delivery model is trusted by national Managed Care Organizations (MCOs), physicians and patients, positioned with over two decades of expertise as the market leader in value-based Home Health, Durable Medical Equipment, and Home Infusion Services. We currently serve over 2 million lives throughout the nation and the Commonwealth of Puerto Rico. 

Join our team as we strive for excellence through teamwork delivering high quality care to our patients through Exceptional Customer Service, Proven Outcomes, and Seamless Care. 

Full time team members competitive compensation package, include but not limited to; 

• Medical, Vision, Dental, Short- and Long-term insurance
• Paid Federal Holidays
• Inclusive rich sick and vacation paid days
• Employer paid life insurance
• 401K with employer contribution
• Wellness program with reward incentives
• Employee recognition and reward programs
• Comprehensive paid training program

What will you be doing: 

This position will be responsible for clinical oversight of reviewing requests for specialized analysis, administrative work and sub-reporting of the overall Home Health Division Quality Assurance Department.  Assist the Director of Home Health Quality Management and Consumer Resolution with processes including but not limited to providing assistance for audit reviews and ensuring timely completion, feedback and reporting on internal issues as well as downstream provider audits as assigned by the HH Director of Quality Management & Consumer Resolutions.

• Reviews accurate data per Medical Doctor (MD) orders and ensures all request for services and care as per contractual arrangements, policy and workflow for coverage of benefits and/or medical necessity both pre or post service and verification of eligibility for types of services as per Health Plan specific direction.
• Interprets medical policy and benefit plan descriptions for covered and medically appropriate benefit decisions.  Uses available resources and guidelines (including but not limited to Health Plan contractual arrangements, Medicare, Medicaid, Milliman guidelines) and other clinical resources, guidelines/ criteria as needed.
• Promotes network provider compliance and quality home health care.
• Processes/reviews beneficiary/patient referrals to provider network, all certifications determined by scripted entry.  Ensures staffed cases have the appropriate discipline and Agency per network direction, requests additional clinical information from Network Providers where applicable. i.e.; updated Physician order and/or complete medical records.
• Identified potential concerns and reports to the Director HHQM for development of recommendations to correct or prevent future concerns.
• Monitors Daily HH pending count report and advises Director of HH, UM Nurse Manager and Referral Coordinator of areas requiring attention and/or course correction.
• Prepares technical reports requiring analysis of policies, procedures and standards and presents to the Director of HHQM for review and follow-up.
• When applicable, completes research regarding beneficiary history prior to determination.  Completes appropriate documentation in designated system for all reviews.
• Refers research and other cases that so not meet guidelines and/or criteria for second level review to Internal Medical Director or Health Plan per department guidelines.
• Pulls and reviews HH Admission Report for monthly NOMNC Audit.
• Request NOMNC Forms from providers as deemed necessary for review by Director of HHQM.
• Responsible for meeting daily production and turnaround times and all contractual arrangements plus handle any provider/beneficiary/health plan calls.
• Provides availability as a resource to Providers, Health Plans, other staff and referral sources while educating and supporting the Quality Assurance Department.
• Participates in on-call, after hours, weekend and holiday support for the department as scheduled.
• Participates in performance improvement activities, staffing meetings, all training activities, committee work to promote the Quality Improvement (QI) Program and other department or company activities.
• Maintains confidentiality and respect of Patient Information in accordance with HIPPA, URAC and company standards, policy and procedures.
• Monitors and reports Network availability, quality concerns or utilization trends and reports to supervisor in a timely manner.  This position may involve review of appeals and responding to health plan inquiries as needed.
• Review documentation medical record for appropriateness and completeness.
• Review documentation for proper visit utilization and documentation skills.
• Maintain knowledge of state and federal regulations and CHAP /JC standards and all changes and updates.
• Perform Chart audits as needed.
• Other duties as assigned.

Join our team as we strive for excellence through teamwork, where our patients are #1! 

IHCS is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.