UM Nurse, LVN

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  • 17-00190
  • Full Time/Contract
  • Case Management
  • Rancho Cucamonga, CA
Job Description
CLIENT COMPANY OVERVIEW
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company to Work For "Favorite Training Program and "Favorite Workplace Culture in their 2014 Winning Workplaces survey.

JOB TITLE
UTILIZATION MANAGEMENT LVN (OUTPATIENT)

DESCRIPTION
Under the general direction of the Utilization Management Manager, the Utilization Management LVN is responsible for working directly with Providers, contracted entities and hospitals to ensure coordinated, continuous cost effective quality healthcare for health plan Members.

  • Responsible for the oversight and/or performance of authorizations of referrals to Providers for consultation and treatment under the direction of the Utilization Management Manager and Senior Medical Director or designee.
  • Responsible for the oversight and/or performance of prospective, concurrent, or retrospective reviews for medical necessity and appropriateness of service and care.
  • Responsible for the oversight and/or performance of authorization of other concurrent, outpatient or ancillary services as per approved clinical criteria, including but not limited to, outpatient surgery, durable medical equipment, home health, etc. within regulatory timeframes.
  • Serves as a resource for Member and Provider Service departments for utilization management, referral, and continuity of care issues.
  • Works with Contracts Department to identify gaps in provider network.
  • Responsible for initiating letters of agreement when referring to out-of-network providers.
  • Responsible for timely and appropriate documentation in the medical management system.
  • Responsible for identifying potential cases for Case Management, Disease Management, Health Management, Health Education and/or quality of care issues and making appropriate referrals when needed.
  • Responsible for identifying alternate payer sources such as CCS, IRC, etc.
  • Responsible for working with Team Members to support the goals of the department and the vision of the organization.
  • Any other duties as required to ensure Plan operations are successful.
  • Ensure the privacy and security of PHI (Protected Health Information) as outlined in policies and procedures relating to HIPAA compliance.

SKILLS & QUALIFICATIONS

  • Possession of a valid LVN license issued by the State of California.
  • Possession of a valid State of California driver’s license.
  • Two (2) or more years of utilization management experience in a health care delivery setting.
  • Experience in an HMO or experience in a Managed Care setting preferred.
  • Knowledge of Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements.

    COMPENSATION | POSITION CLASSIFICATION

  • Commensurate with Experience
  • Full Time | Exempt

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