Performs case processing, clinical evaluation and completion of ER PLP reconsiderations from receipt to adjudication. Utilizes clinical knowledge to evaluate and assess the clinical necessity of ER PLP reconsiderations.
Essential Functions of the Retrospective Review LPN
Communicates with coordinators and Medical Directors, the case disposition of ER PLP reconsiderations.
Reviews medical records against PLP guidelines and recommends a case disposition.
Applies clinical knowledge in the assessment, evaluation and interpretation of clinical notes submitted by the provider.
Evaluates the medical record so that patient age, time of day, severity of injury, availability of medical resources, etc. are considered when adjudicating the PLP case.
Documents the clinical aspects of the case and the reasoning for the determination outcome in numerous databases.
When appropriate, seeks additional clinical advice and recommendations to properly adjudicate the PLP case.
Serves in all phases of the reconsideration process from preloading of cases, case disposition and letter generation. Prepares cases for scanning and archiving.
Verifies eligibility, timeliness and record completeness of ER PLP cases and follows up with the provider as necessary.
Electronically enters claim detail information in organization applications including Sidewinder and documents receipt, disposition and other noteworthy aspects of the cases in the application.
Assists in resolving provider issues through the use of organizational databases and reports, communication with internal departments such as Claims and Appeals and contact/communication with ER PLP clinical coordinators and Medical Directors.
Participates in process development and testing of new process implementation.
Evaluates data input and output for accuracy and ensures compliance with data integrity and corporate compliance directives.
Participates in ad hoc projects that require clinical evaluation of medical records as directed by the Manager and/or Director.
Identifies misuse of ER utilization and resources and communicates with Manager/Director/Medical Director as needed.
Experience required for the Retrospective Review LPN:
Must have experience in Retrospective Review, Utilization review
Managed care or Health Plan experience.
AZ LPN nursing license in good standing and active