Medical Case Manager (LVN) (Concurrent Review)
Posted on: June 6, 2021
Department(s): Utilization Management (Concurrent Review)
Reports to: Supervisor, Utilization Management (Concurrent
FLSA status: Non-Exempt
Salary Grade: K - $70,000 - $98,000
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
- 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
- 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,
- 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
- Establishes means of communication and collaboration with other
team members, physicians, community agencies, and
- 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
- Develop and maintain effective working relationships with all
levels of staff, other programs, agencies, and the public.
- Assess resource utilization, cost management, and negotiate
- Prepare clear, comprehensive written and oral reports and
- Communicate clearly and concisely, both verbally and in writing
at all organizational levels and in situations requiring
instructing, persuading, negotiating, consulting, and
- 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
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.
- 1+ years of Concurrent Review (In-Patient) experience
- Guidelines and regulations relevant to case management and
- 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
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