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SoutheastHEALTH LPN Utilization Review Nurse in Cape Girardeau, Missouri

LPN Utilization Review Nurse

Nursing - Other Cape Girardeau, Missouri Case Management Full-Time



Day ShiftThe Case Management LPN Utilization Review works as part of the Interdisciplinary Team to review medical necessity for all Southeast HEALTH hospital servicesBegin

  • Precertification

  • Reviews all commercial admissions to provide accurate and complete medical information to obtain authorization.

  • Documents all communication with payers in appropriate databases to ensure timely billing.

  • Reviews OR schedule in advance of procedures to ensure that all government and commercial payers that follow the CMS inpatient only list are in the correct status pre-op and check of authorization has been obtained if a commercial payer.

  • Admission Reviews

  • Conducts timely commercial payer reviews for medical necessity as determined by payers

  • Will work with attending physician to ensure a peer to peer is communicated when insurance company is denying the admission status to Southeast HEALTH.

  • Confers with admitting physicians if documentation does not support the level of care and provides coaching on accurate level of care and supporting documentation.

  • Uses MCG to screen for medical necessity of admission for both inpatient and outpatient observation levels of care. Uses physician documentation to support level of care (i.e. H&P, Progress notes) and the need for 2 midnights of hospital care.

  • Will facilitate external physician advisor and attending communication if needed.

  • Identifies and documents avoidable delays related to progression of care, delays in services, or patient flow issues.

  • Will work with the healthcare team to facilitate removal of barriers that are identified.

  • Will escalate any identified barriers through the utilization management committee for any medical necessity issues

  • Continued Stay Reviews

  • Reviews on a continued basis the need for medical services using Milliman Care Guidelines continued stay criteria.

  • Provides continued stay reviews with commercial payer as determined by payer requests.

  • Participates in daily huddles, IDR, and patient care conferences to help with intensity of service documentation and progression of care issues.

  • Will ensure that long stay certification is documented in the medical record for all Medicare patient by day 20 and helps to facilitate documentation if not present.

  • Documents any identified avoidable days to the progression of care.

  • Coaches and assist members of the medical staff to facilitate documentation that reflects severity of illness and intensity of service as part of the medical record.

  • Denials/Appeals

  • The LPN Utilization Review staff will work proactively with the healthcare team and facilitate peer-to-peer reviews with payers and provide documentation of communication

  • Will help to ensure the appropriate clinical information is provided for the appeal process for any medical necessity denial

  • Will assist with providing documentation to the QIO on patient discharge appeals

  • Will escalate any denials as needed to the Supervisor/Director of Case Management

  • Will help to ensure that all Medicare notification letters are provided to the patient in the appropriate timely manner (i.e. the MOON, Initial Important Message and Detailed Notice of Discharge).


  • Graduate of a Practical nursing program with licensure as an (LPN) in the state of Missouri.

  • 2-3 years of acute care experience in the hospital setting required.

  • Knowledge of commercially used evidence-based screening tools such as InterQual or Milliman Care Guidelines