OrangeRecruiter Since 2001
the smart solution for Orange jobs

Medical Case Manager (LVN) (Concurrent Review)

Company: CalOptima
Location: Orange
Posted on: June 6, 2021

Job Description:

Department(s): Utilization Management (Concurrent Review)

Reports to: Supervisor, Utilization Management (Concurrent Review)

FLSA status: Non-Exempt

Salary Grade: K - $70,000 - $98,000

Job Summary

This position provides case management intervention on behalf of members with short term, stable, and predictable courses of illnesses. Responsible for answering the medical appropriateness, quality, and cost effectiveness of proposed hospital/medical/surgical services in accordance with established criteria.

Position Responsibilities:

  • 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.
  • Reviews and evaluates proposed services utilizing medical criteria and/or established policies and procedures.
  • Determines the appropriate action for the service being requested for approval, modification, or denial, and refers to the Medical Director for review when necessary.
  • Reviews inpatient setting requests to determine if surgery and/or medical care is appropriate.
  • Identifies diagnosis and determines need for continuing hospitalizations; monitors the inpatient length of stay as per established guidelines and professional judgment.
  • Initiates contact with patient, family, and treating physicians to obtain additional information or to introduce the role of case management as needed.
  • For short-term cases, conducts a thorough and objective assessment of the member's status including physical, psychosocial, and environmental.
  • Develops, implements, and monitors a care plan through the interdisciplinary team process in conjunction with the individual member and family in internal and external settings across the continuum of care.
  • Provides cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.
  • Assesses member's status and progress; if progress is static or regressive determines reason and encourages appropriate referrals to out-patient case management or make appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
  • Establishes means of communication and collaboration with other team members, physicians, community agencies, and administrators.
  • Prepares and maintains appropriate documentation of patient care and progress within the care plan.
  • Acts as an advocate in the client's best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
  • Collaborates with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem and solving complex cases.
  • Documents clinical information into the case notes along with the rationale for all decisions in the Guiding Care system.
  • Other projects and duties as assigned.

Possesses the Ability To:

  • 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.
  • Develop and maintain effective working relationships with all levels of staff, other programs, agencies, and the public.
  • Assess resource utilization, cost management, and negotiate effectively.
  • Prepare clear, comprehensive written and oral reports and materials.
  • Communicate clearly and concisely, both verbally and in writing at all organizational levels and in situations requiring instructing, persuading, negotiating, consulting, and advising.
  • 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.

Experience & Education:

  • High School diploma or equivalent required.
  • Current, unrestricted Licensed Vocational Nurse (LVN) to practice in the State of California required.
  • 3+ years of Clinical Nursing Experience of which 1+ years experience in a Managed Care setting required.

Preferred Qualifications:

  • 1+ years of Concurrent Review (In-Patient) experience preferred.

Knowledge of:

  • Guidelines and regulations relevant to case management and utilization management.
  • Understand confidentiality and the legal and ethical issues pertaining to case management.
  • ICD-9/ICD-10 and CPT coding requirements.
  • Available community resources.
  • Effective charting practices and guidelines.
  • Available medical treatments and resources.
  • Principles and practices of health care, health care systems, and medical administration.

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.

Keywords: CalOptima, Orange , Medical Case Manager (LVN) (Concurrent Review), Other , Orange, California

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Log In or Create An Account

Get the latest California jobs by following @recnetCA on Twitter!

Orange RSS job feeds