Medical Case Manager (LVN) (PACE - Utilization Management)

CalOptima Health•Garden Grove, CA

7d•Hybrid

About The Position

We are a mission-driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. This position is an integral part of our PACE- Clinic team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Partial Telework. If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum. The Medical Case Manager (LVN) for the Program for All-Inclusive Care for the Elderly (PACE) is responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities, and ancillary providers. You will be responsible for prior authorization, concurrent review and referral related processes which include on-line responsibilities as well as selected off-line tasks. You utilize PACE medical criteria, policies, and procedures to authorize referral requests from medical professionals, clinical facilities, and ancillary providers. You directly interact with provider callers and serve as a resource for their needs. Together, we are building a stronger, more equitable health system.

Requirements

High school diploma or equivalent PLUS 3 years of nursing experience, with 1 year as a nurse reviewer, required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
CPR and First-Aid Certification required or must be obtained within six (6) months of date of hire.
Current unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California.
MCG certification.
Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
Work independently and exercise sound judgment.
Communicate clearly and concisely, both orally and in writing.
Work a flexible schedule; available to participate in evening and weekend events.
Organize, be analytical, problem-solve and possess project management skills.
Work in a fast-paced environment and in an efficient manner.
Manage multiple projects and identify opportunities for internal and external collaboration.
Motivate and lead multi-program teams and external committees/coalitions.
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.

Nice To Haves

Managed care experience.
Concurrent review experience.

Responsibilities

Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
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.
Screens inpatient and outpatient requests for the PACE Medical Director review, gathers pertinent medical information prior to submission to the PACE Medical Director; follows up with the requester by communicating the PACE 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 receipt to include any authorization updates.
Reviews ICD-10, CPT-4, and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the PACE.
Ensures all internal and external PACE authorizations are complete with CPT codes, notes and pertinent information.
Reviews the appropriateness of retro authorizations for review and works with the PACE Medical Director for proper review and authorizations.
Reviews and follows up on denied claims and provider disputes/appeals to ensure accuracy of information and maintain partnerships with our contracted specialty offices.
Refers cases of possible over/under utilization to the PACE Medical Director for proper reporting and reviewing.
Meets PACE productivity and quality of work standards on an ongoing basis.
Assists the manager with identifying areas of need for staff training and maintains current data resources.
Completes other projects and duties as assigned.