Utilization Management Review Nurse LVN Position

1 month 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 assess the medical necessity of services and benefit coverage, ensuring compliance with regulatory requirements and SCFHP policies and procedures.
  • Process authorization reviews by applying clinical criteria, guidelines, and policies, and 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, such as Case Management, Behavioral Health, and community resources.
  • Maintain adherence with CMS and DHCS regulatory requirements, and facilitate the processing of Letters of Agreement with non-contracted Providers for approved medically necessary services.
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 is desirable.
  • 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 is desirable.
  • Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance.
  • Ability to work within an interdisciplinary team structure.
  • Excellent communication skills, including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers, and outside entities.
Working Conditions

The incumbent will work primarily in an office environment, with 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 Requirements

The incumbent must be able to perform the essential functions of this job, with or without reasonable accommodation, including regular bending, reaching, and sitting or standing for extended periods of time.

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