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Utilization Specialist - Licensed Vocational Nurse (LVN) - Days

Job Ref: 26869

Talent Area: LVN

Houston Methodist Hospital
Houston, TX 77030

Area/Department: Case Mgmt&Social Work

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: DAY

Work Week: M - F

Company Profile

Since its founding in 1919, Houston Methodist Hospital has earned worldwide recognition. Houston Methodist Hospital is affiliated with the Weill Medical College of Cornell University and New York-Presbyterian Hospital, one of the nation's leading centers for medical education and research.  Houston Methodist is consistently ranked in U.S. News & World Report’s “Best Hospital” list and was recently named the number one hospital in Texas. FORTUNE magazine has placed Houston Methodist on its annual list of “100 Best Companies To Work For” since 2006.  Houston Methodist Hospital directs millions of research dollars into patient care and offers the latest innovations in medical, surgical and diagnostic techniques. With 1,119 licensed beds, 67 operating rooms and over 6,000 employees, Houston Methodist offers complete care for patients from around the world.

Job Summary

SUMMARY      Utilization Specialists support the Case Manager and Social Worker Team by performing utilization review and utilization management functions to assure that:  Admissions and continued stays are medically necessary.  Care is provided in the appropriate status to ensure and to preserve patient benefits.  Compliance with Federal, State, and Managed Care contract regulations is maintained.  Medical necessity denials and other utilization trends are analyzed, appealed and reported. Utilization functions include preadmission review and management; admission, continued stay, and readmission review; management of observation status patients; precertification and recertification of managed care patients; prebilling review; and medical necessity denial management.      


PAS US Prebilling Denials 

1. Performs concurrent and retrospective review for medical necessity, appropriate level of care and program compliance using InterQual Severity of Illness and In10sity of Service Criteria. Standard for initial review is within 24 hours of entry.    

2. Performs preadmission screening taking deliberate action to influence placement in the appropriate level of care and maintain compliance with EMTALA transfer regulations.  

3. Manages all patients in Observation Status, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital.  

4. Reconciles hospital services provided with patient-specific insurance benefits and communicates with Case Managers, physicians and payers to assure reimbursement.  

5. Documents avoidable days related to level of care and delays.   

6. Denial Management: - Identifies when services no longer meet InterQual criteria and initiates delegated Medicare denial process (HINN-Hospital Notice of Noncoverage) - Tracks all Managed Care medical necessity denials and appeals denials when appropriate. - Assists with governmental agency requests for information, e.g. CMS, Texas Medical Foundation.  

7. Documents reviews and other activities clearly and concisely, according to procedure, in MaxSys II, HIS, and in activity logs. Compiles reports as requested.  

8. Performs prebilling review of Medicare cases to assure that level of care, medical necessity, and documentation are appropriate and meet Federal regulations for compliance and reimbursement.   

9. Maintains collaborative relationships with Patient Access Services, Health Information Management, Documentation Review Specialists, Case Managers and Social Workers. Refers cases to Medical Director, and Performance Improvement as needed.   

10. Utilizes effective communication and negotiation skills with physicians, payers, case managers, and social workers. Provides clear, concise information and recommends solutions for identified issues.   

11. Demonstrates ICARE Values.   

12. Demonstrates ServicePride Standards   

13. Follows all safety rules on the job.      

EDUCATION REQUIREMENTS       RN preferred, LVN with extensive experience with Managed Care/Denial management accepted     

EXPERIENCE REQUIREMENTS       5 years clinical experience; 2 years utilization review experience     



1. Knowledge of Medicare, Medicaid and Managed Care requirements. 

2. Works independently with minimal supervision.   

3. Strong assessment, organizational, problem solving and time management skills.      

4. Demonstrates a positive professional and personal image.    

5. Effectively communicates and resolves conflict. Computer skills - Negotiation skills - Collaboration skills

Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of  race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law.

VEVRAA Federal Contractor – priority referral Protected Veterans requested.