Location: Montebello, CA

Schedule: Full Time / Hours between 8am & 5pm.

Pay: $33 - $46 - Depending on Experience

Job Type: Temporary Assignment

Job Summary: The LVN, Utilization Management Nurse position will provide routine review of authorization requests from all lines of business using respective national/state, health plans, and nationally recognized guidelines. Responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency with coverage guidelines. The UM Nurse determines the medical appropriateness of inpatient and outpatient services following the evaluation of medical guidelines and benefit determination.

Key Responsibilities: 

· Responsible for the daily review and processing of referral authorizations in accordance to turnaround time (TAT) standards set by ICE/Health Plan

· Works collaboratively with Hospitalists, hospital partners, and care teams to provide holistic patient care that is focused on high quality in a cost-effective

· Monitors ongoing services and their cost effectiveness; recommends changes to the plan as needed using clinical evidence-based criteria – Milliman, Interqual, CMS, National Recognized American Academy of Specific Specialty, Health Plan specific criteria.

· Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making

· Maintains up-to-date knowledge of rules and regulations governing utilization management processes;

· Input data into the Medical Management system to ensure timeliness of referral processing.

· Verifies member benefits and eligibility upon receipt of the treatment authorization request.

· Ensure timely provider and member oral and written notification of referral decisions.

· Coordinates with Medical Director or referral specialists for timely referral processing

· Facilitates LOA processing by sending requests to Provider Contracting for non-contracted providers or facilities, when applicable

· Facilitates LOA processing with the Health Plan for non-contracted facilities

· May be responsible for daily concurrent review, retro reviews, discharge planning, pre-certification/prior authorization request review and ensures patients meet appropriate level of care based on acceptable evidenced based criteria.

· Develops a positive working relationship with internal and external customers

· Perform additional duties as assigned.

Work Environment: 

· Work in a medical office environment, climate controlled through central air conditioning.

Required Skills and Abilities:

· Uses computer and computer system (including hardware and software) to perform necessary functions.

· Communicates effectively in writing as for the needs of the audience.

· Demonstrates excellent interpersonal skills.

· Maintains dedicated attention to detail.

· Analyzes and interprets reports and data for management purposes.

· Demonstrate knowledge of DOFRs and delegation agreements

· Adheres to the Clinic Heath services HIPAA Compliance Plan and the Privacy Standards Confidentiality Agreement.

· Knowledge of pre-authorizations and reimbursement regulations pertaining to Medicare, Medi-Cal, Commercial, CCS and other government programs.

· Demonstrated ability to work with automated systems, including electronic medical records and MS Office products such as Word, Excel and Outlook.

· Excellent customer service; ability to be an effective communicator

· Knowledge of federal, state and other applicable standards for clinical practice for assigned area(s) of responsibility.

· Ability to work collaboratively with diverse individuals and situations, including strong problem-solving and conflict-resolution skills.

· Ability to sit, stand, lift (up to 15 lbs.), bend, walk, as required for carrying out duties of positions.

· Graduated from an accredited LVN school with a current LVN license issued by the State of California Vocational Nursing.

· Minimum of 2 years of managed care experience is required.

· BLS Certification is required.