Summary:
The Medical Case Manager (LVN) (Pre-Authorization Nurse Reviewer) will be responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities and ancillary providers. The incumbent will be responsible for prior authorization and referral related processes, including on-line responsibilities and select off-line tasks. The incumbent will utilize CalOptima Health's medical criteria, policies and procedures to authorize referral requests from medical professionals, clinical facilities and ancillary providers. The incumbent will directly interact with provider callers and serve as a resource for their needs.
Duties & Responsibilities:
- Medical Review Support
- 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.
- Verifies and processes specialty referrals, diagnostic testing, outpatient procedures, home health care services and durable medical equipment and supplies via telephone or fax using established clinical protocols to determine medical necessity.
- Screens requests for the Medical Director's review, gathers pertinent medical information prior to submission to the Medical Director, follows up with the requester by communicating the Medical Director's decision and documents follow-ups in the utilization management system.
- Completes required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates.
- Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business.
- Contacts the health networks and/or CalOptima Health's Customer Service department regarding health network enrollments.
- Identifies and reports any complaints to the immediate supervisor utilizing the call tracking system or verbal communication if the issue is urgent.
- Refers cases of possible over/under utilization to the Medical Director for proper reporting.
- Meets productivity and quality of work standards on an ongoing basis.
- Administrative Support
- Assists the manager with identifying areas of staff training needs and maintains current data resources.
- Other
- Completes other projects and duties as assigned.
Minimum Qualifications:
- High School diploma or equivalent required.
- PLUS 3 years of nursing experience required (1 year of which must be as a Clinical Nurse Reviewer)
- 1 year of utilization management/prior authorization review experience 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.*
Preferred Qualifications:
- Active Certified Case Manager (CCM) certification.
- Managed care experience.
Required Licensure / Certifications:
- Current, unrestricted Licensed Vocational Nurse (LVN) license required in the state of California required.
Knowledge & Abilities:
- 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.
- Work in a fast-paced environment and in an efficient manner.
- 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.
Work Schedule:
Monday to Friday - 8:00 a.m. to 5:00 p.m.
Contract Length:
Up to 6 months.
Equiliem Healthcare
specializes in staffing clinical, non-clinical, and allied personnel. We excel in all levels, disciplines, and specialties within the healthcare spectrum. Our projects range from short to long term local and travel assignments. Equiliem has been recognized as a certified small business enterprise. In addition, we are proud that we have earned the prestigious Joint Commission accreditation for staffing firms and have been awarded Best in Staffing 4 years running by our employees and client partners.
Benefits offered to our workers include the following:
- Medical Insurance
- Vision & Dental insurance
- Life Insurance
- 401K
- Commuter Benefits
- Employee Discounts & Rewards
- Payroll Payment Options
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Equiliem
medical insurance, dental insurance, life insurance, 401(k)
Apr 01, 2025