Medical Case Manager; LVN); PACE - Utilization Management

Medical Case Manager (LVN) (PACE - Utilization Management) Cal Optima Join Us in this Amazing Opportunity The Team You'll Join

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

We are hoping you will join us as a Medical Case Manager (LVN) (PACE-Utilization Management) and help shape the future of healthcare where you'll be 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.

• 95% - Case Management
• 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.
• 5% - Other
• Completes other projects and duties as assigned.

• 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.

• Managed care experience.
• Concurrent review experience.

• Current unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California.

• Develop rapport and establish and maintain effective working relationships with Cal Optima 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…