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 considered
  • 1 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 Wage
      
      
      
      PId571db692e37-37248-35375059

Keywords: SUNSHINE ENTERPRISE USA LLC, Orange , Medical Case Manager - Concurrent Review, Healthcare , Orange, California