LVN Case Manager - Utilization Mgmt - Corporate Offices/Telecommuter - Days - FT

Sharp HealthCare

75d • $34,170 - $49,370

About The Position

The CMI performs clinical/medical necessity reviews and authorizes medical services that meet medical criteria. The review of care is region specific and consists of outpatient healthcare services on pre-certification requests, outpatient procedures, outpatient services, elective inpatient admissions, home health services, genetic testing, orthotics, prosthetics and complex durable medical equipment. The CM1 also facilitates referrals to providers or vendors that are region specific while determining medical necessity and appropriateness.

Requirements

• 2 Years Experience in a medical setting (i.e. office, hospital, SNF, medical clinic etc.)
• California Licensed Vocational Nurse (LVN) - CA Board of Vocational Nursing & Psychiatric Technicians -REQUIRED

Nice To Haves

• Experience in managed care

Responsibilities

• Able to identify benefit coverage.
• Assesses requests for services by first reviewing the patient's benefit under the health plan and the criteria of the health plan as to whether that service is covered.
• Reviews for medical necessity and appropriateness of services/care based on health plan members medical condition.
• Authorizes the correct vendor to provide care services reviewing risk matrix and health plan contracted vendor list.
• Communicates the decisions to the appropriate persons and documents per UM policy.
• Applies approved criteria to medical information.
• Consults with supervisor, team lead and/or medical director to discuss requests/care inconsistent to criteria and determine the appropriateness of service/care.
• Works closely with the Care Coordinators to obtain necessary information for clinical reviews for decision making.
• Documents per department policy in IDX, etc.
• Communicates decisions to the requesting provider, facility and member within department's approved guidelines.
• Identifies and refers members to case management or quality management as appropriate for utilization or quality issues while maintaining department processes in compliance with the State and Federal standards.
• Reviews patients for multiple diagnoses, surgeries, age, inpatient/skilled nursing facility admits, repeat same type services for need for further management of health care.
• Gathers pertinent information to provide Case Management with knowledge of patient and issues.
• Keeps current knowledge and understanding of applicable accreditation and regulatory statutes related to health care, managed care, case management practice.
• Serves as a resource and mentor to regional team and other department staff.
• Establish mutually derived annual goals and meet goals.
• Maintains turn-around time for routine, urgent and expedited referrals as outlined in SCMG's Utilization Management Plan.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed