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

About the role

We are seeking a Medical Case Manager (LVN) (PACE-Utilization Management) to join our PACE Clinic team. 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.

Responsibilities

• Reviews and processes requests for authorization and notification of medical services from health professionals, clinical facilities, and ancillary providers.
• 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.
• Maintains PACE productivity and quality of work standards on an ongoing basis.
• Aids the manager with identifying areas of need for staff training and maintains current data resources.

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.

Qualifications

• Managed care experience.
• Concurrent review experience.

Skills

• 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.
• 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.

Benefits

• Competitive compensation.
• CalPERS pension program and additional retirement packages.
• Comprehensive benefits package.
• Tuition Reimbursement.
• Professional development opportunities.
• Career development opportunities.
• Flexible scheduling.

Pay

The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors. Pay Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947).

Schedule

This position is approved for Partial Telework (If the position is Telework, it is eligible in California only).