Medical Case Manager - LVN - Impresiv Health
Orange, CA 92868
About the Job
Title: Medical Case Manager - LVN
Duration: up to 6 months
Compensation: $37.43-$59.89/hour
Description: The Medical Case Manager (LVN) (Concurrent Review) provides case management intervention on behalf of members with short term, stable, and predictable courses of illnesses. The incumbent is responsible for answering the medical appropriateness, quality, and cost effectiveness of proposed hospital/medical/surgical services in accordance with established criteria.
What You Will Do:
You Will Be Successful If:
What You Will Bring:
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!
Duration: up to 6 months
Compensation: $37.43-$59.89/hour
Description: The Medical Case Manager (LVN) (Concurrent Review) provides case management intervention on behalf of members with short term, stable, and predictable courses of illnesses. The incumbent is responsible for answering the medical appropriateness, quality, and cost effectiveness of proposed hospital/medical/surgical services in accordance with established criteria.
What You Will Do:
- 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.
- Analyzes requests with the objective of monitoring utilization of services, this includes medical appropriateness and identifying potential high cost, complex cases for outpatient case management intervention.
- 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 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.
- Completes other projects and duties as assigned.
You Will Be Successful If:
- Evaluate the quality of necessary medical services and be able to acquire and analyze the cost of care.
- Assist in the formulation of medical case management policies and procedures; understand and interpret policies, procedures, and regulations.
- Establish and maintain effective working relationships with leadership and staff.
- Assess resource utilization, cost management, and negotiate effectively.
- Prepare clear, comprehensive written and oral reports and materials.
- Communicate clearly and concisely, both orally and in writing.
- 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.
What You Will Bring:
- High School Diploma or equivalent
- Current and unrestricted LVN license in the state of CA
- 3+ years of experience in Clinical Nursing, 1+ years as a Clinical Nurse Reviewer in UM Prior Authorization required.
- Must be able to utilize medical criteria, policies, and procedures, to authorize referral requests for medical services from medical professionals, clinical facilities, and ancillary providers.
- 1+ years of Concurrent Review (In-Patient) experience preferred
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!
Source : Impresiv Health
