Bridging the gap between your dreams and your current healthcare position.
UM Nurse, LVN
Under the general direction of the Utilization Management Clinical Manager and Supervisor, and within the LVN scope of practice, the incumbent is responsible for working directly with Providers, contracted entities and vendors to ensure coordinated, continuous cost effective quality healthcare for members.
Major Functions (Duties and Responsibilities)
1. Responsible for gathering of clinical documentation to assist the R.N. Letter Review Nurse and Medical Director with decision of prospective/pre-service, concurrent, or retrospective reviews based on clinical criteria for appropriateness of outpatient services and care.
2. Works collaboratively with the UM clinical team to ensure regulatory timeframes are upheld for authorization of concurrent, outpatient or ancillary services as per approved clinical criteria, including but not limited to, outpatient surgery, durable medical equipment, home health, etc.
3. Serves as a resource for Member and Provider Service departments for outpatient utilization management, referral, and continuity of care issues.
4. Works with Contracts Department to identify gaps in provider network.
5. Responsible for assisting with the letter of agreement process when referring to Members to out-of-network providers.
6. Responsible for timely and appropriate documentation in the medical management system.
7. Assist with identifying potential cases for Case Management, Disease Management, Health Education and/or quality of care issues and making appropriate referrals when needed.
8. Assist with identifying alternate payer sources such as CCS, IRC, etc.
9. Responsible for working with Team Members to support the goals of the department and the vision of the organization.
10. Participate in LEAN activities.
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.
High school diploma or GED required.
Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required.
Drivers License Required
Yes, must have a valid California Driver's License.
Knowledge of Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements. ICD-9/10 and CPT coding. Knowledge of capitated managed care environment helpful. Medi-Cal, Medicare and other state/federal Program & Regulations.
Microcomputer skills, proficiency in Windows applications preferred. Proficiency in Excel preferred. Excellent communication and interpersonal skills. Strong organizational skills.