Medical Case Manager - Concurrent Review

Company: Sunshine Enterprise USA LLC
Location: Orange
Posted on: September 1, 2024

Job Description:

Company Overview: Our client is a leading healthcare located in Orange, CA, seeking medical case manager for Concurrent Review. Position Summary: The successful candidate should hold a current, unrestricted Licensed Medical Nurse (LVN) license with 3 years of nursing experience, 1 year as a Clinical Nurse Reviewer along with 1 year of utilization management/prior authorization review experience. Position Responsibilities:Review requests for medical appropriateness using established clinical protocols.Verify and process specialty referrals, diagnostic testing, outpatient procedures, home health care services, and durable medical equipment via telephone or fax.Screen requests for review by the Medical Director, gather necessary medical information, communicate decisions, and document outcomes in the utilization management system.Ensure accurate coding (ICD-10, CPT-4, HCPCS) and coverage verification specific to CalOptima Health's line of business.Address health network enrollments and liaise with Customer Service regarding network-related issues.Identify and report complaints to supervisors and escalate over/under utilization cases to the Medical Director.Maintain productivity and quality standards consistently.Complete additional assignments and projects as assigned.Assist in identifying staff training needs and maintain updated data resources.Experience & Education:Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in California.High School diploma or equivalent required.3 years of nursing experience, including 1 year as a Clinical Nurse Reviewer.1 year of utilization management/prior authorization review experience.An equivalent combination of education and experience may be considered1 year of Concurrent Review (in-patient) experience Necessary Attributes: Establish effective relationships with internal and external stakeholders.Demonstrate independent judgment and decision-making skills.Communicate effectively both verbally and in writing.Flexible schedule availability for evening and weekend events.Strong organizational, analytical, and problem-solving abilities.Proficiency in Microsoft Office (Word, Outlook, Excel, PowerPoint) and job-specific applications/systems. Please see HR for information on physical demands and work environment of this job. Sunshine Enterprise USA is an "Equal Opportunity Employer-Minorities, Females, Veterans and Disabled Persons" Compensation details: 40-55 Hourly WagePI23f8c8f7af67-25660-35375059

Keywords: Sunshine Enterprise USA LLC, Orange , Medical Case Manager - Concurrent Review, Executive , Orange, California