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Clinical Utilization Specialist

2 months ago

Northridge, California, United States Regal Medical Group Full time
Job Overview

Position Summary:

The Case Manager for Prior Authorization, licensed as a Vocational Nurse (LVN), plays a pivotal role in enhancing the quality and cost-effectiveness of healthcare services. This position involves the application of clinical expertise and adherence to established policies and guidelines when evaluating specialty referral requests for prior authorization. The Case Manager will assess the appropriateness of care and settings, approving services when warranted. If services are not deemed appropriate, the Case Manager will escalate requests to the relevant physician or medical director with informed recommendations, ensuring members receive high-quality care in optimal settings while complying with regulatory standards.

Key Responsibilities:
  • Comprehend and advocate for the principles of medical management to ensure timely and suitable care in appropriate environments.
  • Engage in effective communication with healthcare providers, internal staff, and health plans regarding medical management and referral authorization matters.
  • Foster collaborative relationships with colleagues in the PACM team, pre-authorization coordinators, high-risk nurse case managers, inpatient nurse case managers, medical directors, and network management.
  • Investigate alternative care plans and, when necessary, assist in directing members to the most suitable care settings to provide the right care at the right time.
  • Act as a liaison among case managers, UM coordinators, contracted providers, and members/families when needed.
  • Conduct case reviews based on key outpatient screening indicators, evaluating submitted plans of care for completeness, consistency with clinical practice guidelines, and adherence to health plan and CMS regulations.
  • Adhere to regulatory turnaround time standards as mandated.
  • Accurately document all necessary information in authorization notes.
  • Approve requests that meet established protocols.
  • Forward authorization requests requiring physician review, accompanied by a comprehensive case summary and recommendations.
  • Understand applicable capitation contracts and their relevance to review responsibilities.
  • For PACMs involved in Durable Medical Equipment (DME), comprehend contracts and review rental versus purchase approvals, ensuring timely equipment retrieval.
  • When appropriate, evaluate medical necessity and appropriate utilization of ancillary professional services, such as home health, infusion, physical therapy, occupational therapy, and speech therapy.
  • Exhibit the ability to follow through on requests, sharing critical information, and responding promptly to inquiries.
  • Participate in service recovery efforts by following up with dissatisfied patients or providers, gathering information, and demonstrating empathy.
  • Identify network needs and report them to management for potential contracting opportunities.
  • Demonstrate excellent written and verbal communication skills to assist in creating training materials and job aids for staff.
  • Conduct training sessions as required.
  • Perform other duties as assigned by management.
The compensation for this position is anticipated to be around $40 per hour, with variations based on individual factors such as market location, job-related knowledge, licensure, skills, and experience.

The total compensation package may also encompass additional elements, including sign-on bonuses and discretionary awards, along with a comprehensive range of medical, financial, and other benefits, including eligibility for 401(k) and various paid time off benefits.

Details regarding participation in these benefit plans will be provided upon receiving an employment offer.

As one of the rapidly expanding Independent Physician Associations in Southern California, Regal Medical Group fosters a dynamic, engaging, and supportive work environment. We promote teamwork, encourage learning, and support career advancement for all employees, believing that your success contributes to our collective success.

Full-Time Position Benefits:

Employee satisfaction is vital to our organization and the well-being of our members. We are committed to providing our employees with the necessary resources to achieve security and maintain a healthy work-life balance.

Our dedication to our staff is reflected in our comprehensive benefits package, which includes a generous array of employer-paid options.

Health and Wellness:
  • Comprehensive medical, pharmacy, and dental coverage for employees, fully employer-paid
  • Vision insurance
  • No co-payments for employed physician office visits
  • Flexible Spending Account (FSA)
  • Employer-Paid Life Insurance
  • Employee Assistance Program (EAP)
  • Behavioral Health Services
Savings and Retirement:
  • 401k Retirement Savings Plan
  • Income Protection Insurance
Additional Benefits:
  • Vacation Time
  • Company celebrations
  • Employee Referral Bonus
  • Tuition Reimbursement
  • License Renewal CEU Cost Reimbursement Program
  • Business-casual working environment
  • Sick days
  • Paid holidays
  • Mileage reimbursement
Employer will consider qualified applicants with criminal histories in accordance with the LA City Fair Chance Initiative for Hiring Ordinance.

Qualifications:
  • Graduate from an accredited nursing program
  • Active California Licensed Vocational Nurse license
  • Minimum of one year of experience in processing referrals and authorizations
  • Preferred knowledge of healthcare and managed care systems.
  • Familiarity with NCQA, CMS, HSAG, and health plan requirements related to utilization management.
  • Understanding of the pre-authorization process and workflow, with prior authorization experience preferred
  • Proficient in Microsoft Office Suite (Word, Excel, Outlook, Access, PowerPoint)
  • Typing speed of 30 WPM with accuracy
  • Ability to handle confidential matters responsibly
  • Capacity to thrive in a multi-tasking, fast-paced, high-stress environment