Medical Case Manager (LVN) (Utilization Management) (Full Telework/Weekend Work) in Orange, CA

Medical Case Manager (LVN) (Utilization Management) (Full Telework/Weekend Work) - CalOptima - Orange, CA - work from home job Company: CalOptima Job description: Medical Case Manager (LVN) (Utilization Management) (Full Telework/Weekend Work) Job Description Department(s): Utilization Management Reports to: Supervisor, Utilization Management FLSA status: Non-Exempt Salary Grade: K - $33.65 - $51.83 ($70,000 - $107,800) • **Full Telework/Weekend Work***This position is a remote opportunity for Southern California Applicants. In order to be considered, you must live in Southern California or be willing to relocate. The schedule will be Thursday-Monday with Tuesday/Wednesday off or Friday-Tuesday with Wednesday/Thursday off. Job Summary The Medical Case Manager (LVN) is responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities, and ancillary providers. The incumbent will be responsible for prior authorization, concurrent review and referral related processes that includes on-line responsibilities as well as selected off-line tasks. The incumbent utilizes CalOptima's medical criteria, policies, and procedures to authorize referral requests from medical professionals, clinical facilities, and ancillary providers. This position directly interacts with provider callers and serves as a resource for their needs. Position Responsibilities: • Reviews requests for medical appropriateness for inpatient and outpatient services utilizing medical criteria and/or established policies and procedures. • Verifies and processes specialty referrals, diagnostic testing, outpatient procedures, home health care services and durable medical equipment and supplies via telephone or fax by using established clinical protocols to determine medical necessity. • Screen inpatient and outpatient requests for the Medical Director review, gathers pertinent medical information prior to submission to the Medical Director; follows up with the requester by communicating the medical director's decision; documents follow-up in the utilization management system. • Completes required documentation for data entry into the utilization management system at the time of the telephone call of fax to include any authorization updates. • Reviews ICD-10, CPT-4 and HCPCS codes for accuracy and existence of coverage specific to the line of business. • Contacts health networks and/or CalOptima Customer Service regarding health network enrollments. • Identifies and reports any complaints to immediate supervisor utilizing the call tracking system, or through verbal communication if the issue is of urgent nature. • Refers cases of possible over/under utilization to the Medical Director for proper reporting. • Meets productivity and quality of work standards on an ongoing basis. • Assists Manager with identifying areas of staff training needs and maintains current data resources. • Other projects and duties as assigned. Possesses the Ability To: • Use problem-solving, organizational, and time management skills, along with the ability to work in a fast-paced environment. • Communicate clearly and concisely, both verbally and in writing at all organizational levels. • Develop and maintain effective working relationships with all levels of staff, other programs, agencies, and the public. • Prepare clear, comprehensive written and oral reports and materials. • Travel to locations with frequency as the employer determines is necessary or desirable to meet its business needs. • Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Experience & Education: • Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the State of California required • 3 years of Nursing experience, with 1 year as a Clinical Nurse Reviewer, required. Preferred Qualifications: • Current, unrestricted Registered Nurse (RN) license to practice in the State of California preferred. • Managed care experience preferred • Concurrent review experience preferred. Knowledge of: • Guidelines and regulations relevant to utilization management. • Medical • Medi-Cal and Medicare benefits and regulations. • Current CPT-4, ICD-10, and Healthcare Common Procedure Coding System (HCPCS) codes and continual updates to knowledge base regarding the codes. • Available community resources. • Effective charting practices and guidelines. • Available medical treatments and resources. • Principles and practices of health care, health care systems, and medical administration. CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134. Expected salary: Location: Orange, CA Job date: Tue, 05 Sep 2023 03:40:45 GMT Apply for the job now! Apply tot his job