Utilization Management Review Nurse LVN

Santaclara Family Health Plan•San Jose, CA

27d

About The Position

Under the guidance and direction of the UM department RN Manager or Director, the Utilization Management Review Nurse (LVN) performs prospective and retrospective clinical review for inpatient and outpatient authorization requests in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and applicable business requirements. Following regulatory or evidence-based guidelines, assesses for medical necessity of services and/or benefit coverage which result in approved determination for services or the need to collaborate with Medical Directors for potential denial considerations.

Requirements

Active California Board of Nursing Licensed Vocational Nurse License (LVN) without restriction. (R)
Minimum one year of licensed related health care experience. (R)
Knowledge of managed care principles and practices with emphasis in Utilization Management and/or Case Management. (R)
Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)
Ability to successfully pass departmental bi-annual inter-rater reliability testing. (R)
Ability to work within an interdisciplinary team structure. (R)
Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the operations as dictated by business needs. (R)
Working knowledge of and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word, Excel, and specific case management programs. (R)
Ability to use a keyboard with moderate speed and accuracy. (R)
Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing as mandated by nursing scope of practice. (R)
Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
Ability to maintain confidentiality. (R)
Ability to comply with all SCFHP policies and procedures. (R)
Ability to perform the job safely and with respect to others, to property and to individual safety. (R)

Nice To Haves

One year of experience within a Managed Care Health Plan. (D)
Knowledge of MediCal and/or Medicare guidelines and regulations. (D)
Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria or standards. (D)

Responsibilities

Conduct clinical review to ensure effective and appropriate utilization of benefits and services for prospective, concurrent and retrospective/claims review organization determination authorization requests within regulatory turnaround requirements for all SCFHP lines of business.
Process authorization reviews by applying the appropriate clinical criteria/guidelines, policies and procedures.
Draft and process timely notification of action (NOA) letters for authorization determinations to providers and to members, in member specific language preferences as identified within member demographic information.
Coordinate referrals to appropriate departments or programs for member identified continuity of care needs, such as Case Management, Behavioral Health, Managed Long Term Services and Supports (MLTSS), community resources, Pharmacy and Quality.
Maintain adherence with CMS (Medicare) and DHCS (Medi-Cal) regulatory requirements.
Facilitate appropriate processing of Letters of Agreement with non-contracted Providers for approved medically necessary services.
Perform other duties as required or assigned.

Stand Out From the Crowd

Upload your resume and get instant feedback on how well it matches this job.

Upload and Match Resume