Utilization Management Nurse LVN
2 weeks ago
Utilization Management Nurse LVN
Position Type: Telecommute
Schedule: M-F, 8:00 am – 5:00 pm
JOB SUMMARY
As a Utilization Management Nurse LVN, you will play a crucial role in the healthcare delivery process by:
1. Collecting and reviewing clinical documentation to support the R.N. Letter Review Nurse and Medical Director in evaluating the appropriateness of outpatient services and care based on established clinical criteria.
2. Collaborating with the Utilization Management clinical team to ensure compliance with regulatory timelines for the authorization of outpatient and ancillary services, including but not limited to outpatient surgeries and home health services.
3. Acting as a key resource for Member and Provider Service departments regarding outpatient utilization management, referrals, and continuity of care.
4. Working alongside the Contracts Department to identify and address gaps within the provider network.
5. Assisting in the letter of agreement process for referrals to out-of-network providers.
6. Ensuring timely and accurate documentation within the medical management system.
7. Identifying potential cases for Case Management, Disease Management, Health Education, and quality of care issues, and making appropriate referrals as necessary.
8. Assisting in the identification of alternative payer sources such as CCS and IRC.
9. Collaborating with team members to achieve departmental goals and align with the organization's vision.
10. Participating in LEAN initiatives to enhance operational efficiency.
QUALIFICATIONS
- A minimum of two (2) years of experience in utilization management within a healthcare setting.
- Preferred experience in an HMO or Managed Care environment.
- Possession of a valid and unrestricted Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians.
- Valid Driver's License required.
- Familiarity with Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements, as well as ICD-9/10 and CPT coding. Knowledge of capitated managed care environments is advantageous.
INDH
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