Our client is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. They are also one of the largest employers in the region. They provide quality, accessible healthcare services to more than 1.2 million members. Their mission and core values help guide them in the development of innovative programs and the creation of an award-winning workplace.
Under the general direction of the Utilization Management Clinical Manager and Supervisor, and within the LVN scope of practice, the incumbent is responsible for working directly with Providers, contracted entities and vendors to ensure coordinated, continuous cost-effective quality healthcare for Members.
Major Functions (Duties and Responsibilities)
- Responsible for gathering of clinical documentation to assist the R.N. Letter Review Nurse and Medical Director with the decision of prospective/pre-service, concurrent or retrospective reviews based on clinical criteria for appropriateness of outpatient services and care.
- Works collaboratively with the UM clinical team to ensure regulatory timeframes are upheld for authorization of concurrent, outpatient or ancillary services as per approved clinical criteria, including but not limited to, outpatient surgery, durable medical equipment, home health, etc.
- Serves as a resource for Member and Provider Service departments for outpatient utilization management, referral, and continuity of care issues.
- Works with the Contracts Department to identify gaps in the provider network.
- Responsible for assisting with the letter of agreement process when referring to Members to out-of-network providers.
- Responsible for timely and appropriate documentation in the medical management system.
- Assist with identifying potential cases for Case Management, Disease Management, Health Education and/or quality of care issues and making appropriate referrals when needed.
- Assist with identifying alternate payer sources such as CCS, IRC, etc.
- Responsible for working with Team Members to support the goals of the department and the vision of the organization.
- Two (2) or more years of utilization management experience in a health care delivery setting
- Experience in an HMO or experience in a Managed Care setting preferred.
- Knowledge of Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements.
- Possess an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN
- Drivers License Required
- Microcomputer skills, proficiency in Windows applications preferred. ICD-9/10 and CPT coding Professional demeanor, excellent communication and interpersonal skills, strong organizational skills.
- Knowledge of capitated managed care environment helpful.
- Experience in Excel preferred
- Medical, Medicare and other states/federal Program & Regulations
- Commitment to Team Culture