Prior Auth LVN
3 weeks ago
Position Summary:
The role of the Case Manager, Prior Authorization LVN is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization specialty referral requests. The Case Manager, Prior Authorization LVN will review for appropriate care and setting, and following guidelines/policies, will approve services when indicated. If not indicated, they will forward requests to the appropriate physician or medical director with recommendations for other determinations, ensuring that the member is receiving the appropriate quality care in a preferred setting, while making sure regulatory guidelines are followed
Essential Duties and Responsibilities include the following:
- Understand, promote and review with the principles of medical management to facilitate the right care at the right time in the right setting.
- Communicate effectively and interact with providers, staff and health plans daily or as indicated regarding medical management and referral authorization issues.
- Maintain a working relationship with PACM colleagues, the pre-auth coordinator team, high-risk nurse case managers, inpatient nurse case managers, medical directors, and network management.
- Research alternative care plans and when necessary, assist in the routing of members to the most appropriate care/setting, in order to provide right care/right setting.
- When necessary, act as liaison between the case managers, UM coordinators, contracted providers (PCPs/specialists/ancillary), and the members/families.
- Perform case reviews base on key screening outpatient indicators, and evaluate the PCP submitted plan of care for its completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to standard evidence-based or consensus guidelines, and health plan and CMS guidelines and/or medical policies.
- Maintain regulatory Turnaround Time Standards per regulatory guidelines.
- Document accurately and completely all necessary information in authorization notes.
- Approve those approvable requests as indicated based on protocols.
- Forward those authorization requests needing physician review with an accurate summary of the case, and recommendation.
- Understand all applicable capitation contracts and how they apply to review duties.
- For those PACMs involved in DME, understand the contracts, and need to review rental vs. purchase approvals, and continued use so that equipment is picked up when needed.
- When appropriate, coordinate and review for medical necessity and appropriate utilization any ancillary professional services, i.e. (home health, infusion, PT, OT, ST, etc.).
- Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
- Participates in “service recovery” through follow-up with an upset patient or provider, gathering information, and demonstrating empathy.
- Identifies network needs and report to management for potential contracting opportunities.
- All other duties as directed by management.
- Proactively support and practice company mission, vision and values.
- Follow Employee Handbook guidelines and company policies and procedures.
- Follow established departmental dress code.
- Appropriately and accurately maintain time keeping records.
- Adhere to attendance policy and time off requests.
- Follow safety policies and procedures.
- Be flexible and adaptable and courteous and promote professionalism.
- Communicate verbally and in writing through appropriate channels.
- Maintain confidentiality at all times in compliance with company policy and HIPAA requirements.
- Employee has completed all required annual Compliance training and signed attestation form is attached for each module.
The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.
Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.
Full Time Position Benefits:
The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.
Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.
Health and Wellness:
- Employer-paid comprehensive medical, pharmacy, and dental for employees
- Vision insurance
- Zero co-payments for employed physician office visits
- Flexible Spending Account (FSA)
- Employer-Paid Life Insurance
- Employee Assistance Program (EAP)
- Behavioral Health Services
- 401k Retirement Savings Plan
- Income Protection Insurance
- Vacation Time
- Company celebrations
- Employee Assistance Program
- Employee Referral Bonus
- Tuition Reimbursement
- License Renewal CEU Cost Reimbursement Program
- Business-casual working environment
- Sick days
- Paid holidays
- Mileage
Requirements
Education and/or Experience:
- Graduate from an Accredited Nursing Program
- Active California Licensed Vocational Nurse license
- Minimum of 1 year of processing referrals and authorizations experience
- Knowledge of Healthcare and Managed Care preferred.
- Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management.
- Knowledgeable with the pre authorization process and workflow, with prior authorization experience preferred
- Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
- Typing 30 WPM with accuracy
- Ability to deal with responsibility with confidential matters
- Ability to work in a multi-task, fast-paced, high-stress environment
-
Insurance Auth Rep
2 months ago
West Allis, United States Solve IT Strategies, Inc. Full timeSolve IT Strategies is looking for an Insurance Auth Rep. This role is located at West Allis, WI. This is a contract job onlyThe Main Responsibilities of a person are:Insurance authorization – will be working with an Excel spreadsheet to gather and transfer data to the UHC (United Healthcare) portal. Must be knowledgeable in Microsoft Office, especially...
-
Insurance Auth Rep
3 weeks ago
West Allis, United States Solve IT Strategies, Inc. Full timeSolve IT Strategies is looking for an Insurance Auth Rep. This role is located at West Allis, WI. This is a contract job onlyThe Main Responsibilities of a person are:Insurance authorization – will be working with an Excel spreadsheet to gather and transfer data to the UHC (United Healthcare) portal. Must be knowledgeable in Microsoft Office, especially...
-
Prior Authorization Nurse
4 weeks ago
Covina, United States Regal Medical Group Full time**Position Summary**: **Essential Duties and Responsibilities include the following**: - Understand, promote and review with the principles of medical management to facilitate the right care at the right time in the right setting. - Communicate effectively and interact with providers, staff and health plans daily or as indicated regarding medical management...
-
LVN - Overnight
2 weeks ago
Covina, United States Maxim Healthcare Service Full time$26 - $28 Maxim Healthcare is looking for a Licensed Vocational Nurse (LVN)/Licensed Practical Nurse (LPN) who assumes responsibility and accountability for the application of the nursing process and the delivery of patient/client care. The LVN/LPN is also responsible for providing services, as directed by contract and/or program, while under the supervision...
-
Treatment Nurse
3 weeks ago
Covina, United States Eastland Sub-Acute & Rehabilitation Center Full timeWe are seeking to hire a Treatment Nurse - Licensed Vocational Nurse to join our team! We are a skilled nursing facility looking for dynamic associates to join our clinical team and provide our residents with a best-in-class care experience. Whether you are just starting your career or have years of experience we want to meet you!WE CARE ABOUT YOUR GROWTH!...
-
Treatment Nurse
3 weeks ago
Covina, United States Eastland Sub-Acute & Rehabilitation Center Full timeWe are seeking to hire a Treatment Nurse - Licensed Vocational Nurse to join our team! We are a skilled nursing facility looking for dynamic associates to join our clinical team and provide our residents with a best-in-class care experience. Whether you are just starting your career or have years of experience we want to meet you!WE CARE ABOUT YOUR GROWTH!...
-
Treatment Nurse
5 days ago
Covina, United States Eastland Sub-Acute & Rehabilitation Center Full timeWe are seeking to hire a Treatment Nurse - Licensed Vocational Nurse to join our team! We are a skilled nursing facility looking for dynamic associates to join our clinical team and provide our residents with a best-in-class care experience. Whether you are just starting your career or have years of experience we want to meet you!WE CARE ABOUT YOUR GROWTH!...
-
Treatment Nurse
5 days ago
Covina, United States Eastland Sub-Acute & Rehabilitation Center Full timeWe are seeking to hire a Treatment Nurse - Licensed Vocational Nurse to join our team! We are a skilled nursing facility looking for dynamic associates to join our clinical team and provide our residents with a best-in-class care experience. Whether you are just starting your career or have years of experience we want to meet you!WE CARE ABOUT YOUR GROWTH!...
-
Outpatient Case Manager RN/LVN, Clinic-Based
2 weeks ago
West Covina, United States Heritage Provider Network Full timeJob DescriptionPosition Summary: The Outpatient Case Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified High Risk members. The Outpatient Case Manager will assess and develop a care plan in collaboration with the admitting, attending and consulting physician, the member and...
-
Outpatient Case Manager
4 weeks ago
Covina, United States REGAL MEDICAL GROUP, INC Full time**Position Summary**: The Outpatient Case Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified High Risk members. The Outpatient Case Manager will assess and develop a care plan in collaboration with the admitting, attending and consulting physician, the member and other health...
-
Continuous Care Nurse
2 weeks ago
Covina, United States Absolute Hospice Agency LLC Full timeAbsolute Hospice Agency, LLC. is currently looking for **License Vocational Nurses** to join our ever expanding team of Healthcare Professionals in the field of Hospice! Under the direction of a **License Vocational Nurses**, the Hospice Licensed Vocational (LVN) will provide skilled nursing and palliative care for assigned hospice patients. He/She will be...
-
Surgical Tech Iii
6 days ago
West Covina, United States Emanate Health Full time**Current Emanate Health Employees - Please log into your Workday account to apply**: Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow...
-
Full Time Certified Nursing Assistant
4 weeks ago
West Covina, California, United States Masonic Homes of California Full timeCERTIFIED NURSING ASSISTANTEntity: Masonic Homes of California Payroll Type: Non-ExemptDepartment: Administration Supervisory: NoReports To: Administrator Work Status: Full-TimeLocation of Job: CovinaSchedule: PM ShiftThe pay range for this position is $ $25.00/hour_____________________________________________________________________________JOB CULTUREThe...
-
Full Time Certified Nursing Assistant
3 weeks ago
West Covina, California, United States Masonic Homes of California Full timeCERTIFIED NURSING ASSISTANTEntity: Masonic Homes of California Payroll Type: Non-ExemptDepartment: Administration Supervisory: NoReports To: Administrator Work Status: Full-TimeLocation of Job: CovinaSchedule: PM ShiftThe pay range for this position is $ $25.00/hour_____________________________________________________________________________JOB CULTUREThe...
-
Full Time Certified Nursing Assistant
3 weeks ago
West Covina, California, United States Masonic Homes of California Full timeCERTIFIED NURSING ASSISTANTEntity: Masonic Homes of California Payroll Type: Non-Exempt Department: Administration Supervisory: No Reports To: Administrator Work Status: Full-Time Location of Job: Covina Schedule: NOC Shift, 10:30pm to 7:00amThe pay range for this position is $ $25.00/hour...
-
Full Time Certified Nursing Assistant
3 weeks ago
West Covina, California, United States Masonic Homes of California Full timeCERTIFIED NURSING ASSISTANTEntity: Masonic Homes of California Payroll Type: Non-Exempt Department: Administration Supervisory: No Reports To: Administrator Work Status: Full-Time Location of Job: Covina Schedule: NOC Shift, 10:30pm to 7:00amThe pay range for this position is $ $25.00/hour...
-
LVN Charge Nurse
2 months ago
George West, United States Regency Integrated Health Services Full timeJob Details Job Location: Live Oak Nursing and Rehabilitation Center - George West, TX Position Type: PRN Salary Range: Undisclosed Job Category: Nurse Description Primary Responsibilities The LVN Charge Nurse will assist in ensuring the provision of quality care that promotes the highest practicable physical, mental and psychological well-being of...
-
LVN Charge Nurse
3 weeks ago
George West, United States Regency Integrated Health Services Full timeJob Details Job Location: Live Oak Nursing and Rehabilitation Center - George West, TX Position Type: PRN Salary Range: Undisclosed Job Category: Nurse Description Primary Responsibilities The LVN Charge Nurse will assist in ensuring the provision of quality care that promotes the highest practicable physical, mental and psychological well-being of...
-
WI- Insurance Auth Rep
2 months ago
West Allis, United States Medix Full timeSchedule Details/Additional Information: Monday - Friday 8am-5pm Maintains, confirms and secures referrals, authorization, or pre-certifications required for patients to receive physician or medical services. Verifies the accuracy and completeness of patient account information. Maintains database of payer authorization requirements. Ensures information...
-
WI- Insurance Auth Rep
3 weeks ago
West Allis, United States Medix Full timeSchedule Details/Additional Information: Monday - Friday 8am-5pm Maintains, confirms and secures referrals, authorization, or pre-certifications required for patients to receive physician or medical services. Verifies the accuracy and completeness of patient account information. Maintains database of payer authorization requirements. Ensures information...
