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Utilization Management Nurse LVN
2 months ago
Position Type: Telecommute
Schedule: Monday to Friday, 8:00 AM – 5:00 PM
JOB SUMMARY
The Utilization Management Nurse LVN plays a crucial role in the healthcare delivery system by:
1. Collecting clinical documentation to support the Registered Nurse and Medical Director in making informed decisions regarding prospective, concurrent, or retrospective reviews based on clinical criteria for outpatient services and care.
2. Collaborating with the Utilization Management clinical team to ensure compliance with regulatory timelines for the authorization of concurrent, outpatient, or ancillary services according to established clinical criteria, including but not limited to outpatient surgeries, durable medical equipment, and home health services.
3. Acting as a resource for Member and Provider Service departments regarding outpatient utilization management, referrals, and continuity of care matters.
4. Coordinating with the Contracts Department to identify deficiencies within the provider network.
5. Assisting in the letter of agreement process when referring members to out-of-network providers.
6. Ensuring timely and accurate documentation within the medical management system.
7. Aiding in the identification of potential cases for Case Management, Disease Management, Health Education, and quality of care concerns, making appropriate referrals as necessary.
8. Assisting in identifying 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
- Minimum of two (2) years of experience in utilization management within a healthcare environment.
- Preferred experience in an HMO or Managed Care setting.
- Possession of a valid, unrestricted, and unencumbered 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 standards, as well as ICD-9/10 and CPT coding. Knowledge of capitated managed care environments is advantageous. Understanding of MediCal, Medicare, and other state and federal programs and regulations.
Company: Alura Workforce Solutions
