LVN Case Manager Psych - UR - Loan Forgiveness - Full Time, Days (Culver City)

Prospect Medical Holdings•Culver City, CA

49d•$38 - $51•Onsite

About The Position

The Case Manager, UR is responsible for overseeing the daily operations of the assigned caseload. Ensures Medical Necessity for patient admission and concurrent stay at the short-term acute hospital level of care are met, utilizing the facility approved non-MD reviewer guidelines. Communicates as appropriate to the payer. Refers all cases not meeting MN for second level review. Ensures a safe and timely discharge / transition to the next appropriate level of care. Ensures timely escalation of unresolved care coordination issues to the appropriate level/entity. Enters delays in service and avoidable days regarding exceeded payer LOS variances. Communicates denials and physician related utilization management practices to immediate supervisor same day as identified. Keeps facility administration and CM Manager / Director of Utilization Management aware of any daily operational / physician related issues. Works closely with the facility Physician Advisor and Corporate. Works collaboratively with health care team, patients and families, administration and members of the Medical Staff. Responsible for active participation in daily weekday intra disciplinary patient rounding. Completes TAR for assigned Medi-Cal patient population/ obtains authorizations for managed care accounts and submits appeals for all denied cases. Maintains confidentiality of all information according to Hospital Policy and Procedure and legal and regulatory requirements. Reviews hospital admissions and continued stays in accordance with procedures, criteria, and standards approved by the medical staff. Identifies opportunities for improvement in the current processes and procedures. Escalates unresolved issues to direct supervisor of UM Facility Administrator per escalation process. Collaborates with Social Services, Clinical Team, patient and families to prepare patient's discharge planning needs. Oversees appropriate DC documentation. Works with Social Service to perform a variety of miscellaneous services, such as arranging for discharge or post-hospital plans, placement of patients in skilled nursing facilities or board and care homes.

Requirements

Current Licensure as a Vocational Nurse or LPT in the State of California
Two (2) years of experience in utilization review/management in a managed care or hospital setting.
Knowledge of The Joint Commission and Title XXII regulations
Knowledge of CMS, MCARE, MEDI-CAL and Managed Care Reimbursement.
Knowledge in insurance authorization and verification
Knowledge of Interqual and /or Milliman Care criteria
Excellent written and verbal communication skills in English
Computer/EMR Proficiency
AHA Basic Life Support
De-escalation certification upon hire; Upon recertification, SAMA Certification required
Hospital Fire and Life Safety Card (Los Angeles City Employees only)

Nice To Haves

Three (3) years clinical experience in psychiatric hospital setting.
Care Management Proficiency with Milliman Care Guidelines or Interqual

Responsibilities

Overseeing the daily operations of the assigned caseload
Ensuring Medical Necessity for patient admission and concurrent stay at the short-term acute hospital level of care are met
Communicating as appropriate to the payer
Referring all cases not meeting MN for second level review
Ensuring a safe and timely discharge / transition to the next appropriate level of care
Ensuring timely escalation of unresolved care coordination issues to the appropriate level/entity
Entering delays in service and avoidable days regarding exceeded payer LOS variances
Communicating denials and physician related utilization management practices to immediate supervisor same day as identified
Keeping facility administration and CM Manager / Director of Utilization Management aware of any daily operational / physician related issues
Working closely with the facility Physician Advisor and Corporate
Working collaboratively with health care team, patients and families, administration and members of the Medical Staff
Responsible for active participation in daily weekday intra disciplinary patient rounding
Completes TAR for assigned Medi-Cal patient population/ obtains authorizations for managed care accounts and submits appeals for all denied cases
Maintaining confidentiality of all information according to Hospital Policy and Procedure and legal and regulatory requirements
Reviews hospital admissions and continued stays in accordance with procedures, criteria, and standards approved by the medical staff
Identifying opportunities for improvement in the current processes and procedures
Escalating unresolved issues to direct supervisor of UM Facility Administrator per escalation process
Collaborating with Social Services, Clinical Team, patient and families to prepare patient's discharge planning needs
Overseeing appropriate DC documentation
Working with Social Service to perform a variety of miscellaneous services, such as arranging for discharge or post-hospital plans, placement of patients in skilled nursing facilities or board and care homes