Utilization Review Coordinator (LVN) - Managed Care

Prime Healthcare•Victorville, CA

1d•Onsite

About The Position

Desert Valley Medical Group is affiliated with Desert Valley Hospital, an award-winning facility recognized as one of the nation’s “100 Top Hospitals” and rated “A” for patient safety. The organization is committed to quality, compassion, and community, offering opportunities for professional growth within a community dedicated to making a difference. Key services provided to the community include heart care, emergency services, labor and delivery, and surgical services. The Utilization Review Coordinator (LVN) is responsible for reviewing patient medical information from various sources to assess, identify, plan, monitor, develop, and coordinate appropriate, cost-effective care for all PMG/IPA capitated members who present significant medical risks/liabilities. This role covers both ambulatory and institutional settings, including acute inpatients, catastrophic cases, chronic cases, transplant/AIDS cases, institutionalized cases, and any member requiring continuity and coordination of care, transition of medical care, behavioral health care, or community resources. The position requires the ability to work independently, exercise sound judgment, and possess knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, and lower levels of care for continuity of treatment.

Requirements

Knowledge of Utilization Management/Case Management terminology and functions, in both Managed Care and Non-Managed Care environments.
At least one year of experience as a Case Manager in an acute care setting or related field and coding chart review for meeting criteria purposes.
Basic to intermediate computer knowledge.
Must have a valid RN/LVN California License.

Responsibilities

Coordinates interviews and reviews all medical records, as assigned to caseload.
Actively participates in Case Management and Committee Team meetings.
Responsible for reviewing patient medical information from medical records and various sources in order to assess, identify, plan, monitor, develop, and coordinate appropriate, cost effective care for all the PMG/IPA capitated members that present significant medical risks/liabilities, in the ambulatory and institutional settings.
Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients and families, Interdisciplinary Care Team and all other committees as appropriate.