Medical Management Specialist, LVN

The Role

The Medical Management Specialist-LVN promotes and supports the quality, medical necessity and cost effectiveness of care and services based on State and Federal regulatory guidelines and Medical Policy. Using established clinical criteria and working under the auspices of the Clinical Supervisor, the Medical Management Specialist-LVN is responsible for supporting the utilization management processes related to coverage decision, managing requests for items and/or services. Conducts pre-service and concurrent review following established guidelines in collaboration with Medical Director as secondary reviewer. Applies case management principles and practices to ensure complex medical needs, care and service are coordinated.

Qualifications

• Graduation from an accredited school of Licensed Vocational Nursing or equivalent clinical experience.
• Current and active California Licensed Vocational Nurse is required.
• Certified Professional of Utilization Management (CPUM or CPUR) or other Medical Case Management certification is preferred, or willing to attain such certification with 2 years.
• 3+ years of experience in medical-surgical nursing.
• 3+ years of Utilization Management/Prior Authorization experience in a Managed Care medical group, IPA, or managed care setting.
• Knowledge of (California) managed care industry, Medicare/MediCal required.
• Knowledge of Federal and State healthcare mandates and regulations.
• Health plan and vendor contracting knowledge.
• Proficient in Microsoft Word, Excel, Outlook, and PowerPoint, required.
• Strong analytic and problem-solving skills, required.
• Strong verbal and written communication skills, required.
• Able to multitask and work closely with department RNs.
• Able to work well in a fast-paced and dynamic environment.
• ICD-9, HCPCS and CPT coding knowledge.

Benefits

• Annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• Eleven paid holidays per year, plus 1 additional floating holiday, plus 1 birthday holiday
• Excellent 401(k) Retirement Saving Plan with employer match
• Roadwork program
• Employee recognition program
• Tuition reimbursement

Pay

Base salary range: $30.77 to $44.52 per hour

Schedule

Remote role - CA LVN required

Position will work Monday - Friday 9am - 6pm Pacific Time Zone