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Utilization Management Review Nurse LVN Position
2 months ago
We are seeking a skilled Utilization Management Review Nurse LVN to join our team at Santa Clara County 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 assess the medical necessity of services and benefit coverage for prospective, concurrent, and retrospective/claims review organization determination authorization requests.
- Apply clinical criteria/guidelines, policies, and procedures to process authorization reviews and make informed decisions.
- Draft and process timely notification of action (NOA) letters for authorization determinations to providers and members.
- Coordinate referrals to appropriate departments or programs for member-identified continuity of care needs.
- Maintain adherence with CMS and DHCS regulatory 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.
This position is primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.
Physical RequirementsIncumbents must be able to perform the essential functions of this job, with or without reasonable accommodation.
