Utilization Management Review Nurse LVN

6 days ago


San Jose, California, United States Santa Clara Family Health Plan Full time
Job Summary

We are seeking a skilled Utilization Management Review Nurse LVN to join our team at Santa Clara Family Health Plan. As a key member of our Health Services department, you will play a critical role in ensuring the effective and appropriate utilization of benefits and services for our members.

Key Responsibilities
  • Conduct clinical reviews to ensure compliance with regulatory requirements, SCFHP policies, and procedures.
  • Assess medical necessity of services and benefit coverage, making determinations for approved services or collaborating with Medical Directors for potential denial considerations.
  • Process authorization reviews by applying clinical criteria, guidelines, and policies.
  • Draft and process timely notification of action (NOA) letters for authorization determinations.
  • Coordinate referrals to appropriate departments or programs for member continuity of care needs.
Requirements
  • Active California Board of Nursing Licensed Vocational Nurse License (LVN) without restriction.
  • Minimum one year of licensed related health care experience.
  • One year of experience within a Managed Care Health Plan.
  • Knowledge of managed care principles and practices, with emphasis in Utilization Management and/or Case Management.
  • Knowledge of MediCal and/or Medicare guidelines and regulations.
  • Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance.
Working Conditions

This role is primarily performed in an office environment, with frequent contact with and interruptions by co-workers, supervisors, and plan members or providers.

Physical Requirements

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation.



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