LVN Utilization Management Review Nurse (Hybrid)

LVN Utilization Management Review Nurse (Hybrid) Golden Coast

MSO - 2.0

Riverside, CA Job Details Part-time | Full-time $30 - $40 an hour 14 hours ago Benefits Health insurance Paid time off Qualifications Computer operation Medicare LVN CMS High school diploma or

GED ICD-9 ICD-10 CMS

regulatory compliance Medicare regulations Utilization management Resource utilization in healthcare Computer skills Clinical documentation standards Full Job Description Position Summary/Position Under the general direction of the Operations Director with supervision and accountability to the Medical Director and within the LVN scope of practice, the LVN UM Review Nurse is responsible for working directly with Providers, contracted entities and vendors to ensure coordinated, continuous quality healthcare for plan embers. This position is available as in-office or hybrid, allowing for flexibility based on business needs and employee preference. Additionally, it provides opportunities for growth and leadership development. Major Functions (Duties And Responsibilities) Responsible for gathering of clinical documentation to assist the Medical Director with decision of prospective/pre-service, concurrent or retrospective reviews based on clinical criteria for appropriateness of outpatient and inpatient services and care. Under the supervision and direction of the medical director, assist in preparation of service denial letters and notices. Familiarity with Apollo Managed Care Guidelines is preferred. Strong written communication skills are required. Responsible for concurrent hospital, SNF, and home health review. Receive regular care updates from attending providers and care coordinators. Review admission for medical necessity and appropriate average length of stay and prepare recommendations for medical director. Arrange transition of care between patient settings including discharging and receiving coordination and referral submission and approval. Responsible for preparation of regular status reports and updates to partnered IPA and physician groups. Participate in preparation of delegated reports for payers and regulatory bodies. Works collaboratively with the UM team to ensure regulatory timeframes are upheld for authorization of concurrent, outpatient or ancillary services as per approved clinical criteria, including but not limited to, specialist referrals, outpatient surgery, durable medical equipment, home health, etc. Serves as a resource for Golden Coast MSO Member and Provider Service departments for utilization management, referral, and continuity of care issues. Works with Contracts Department to identify gaps in provider network. Responsible for assisting with the letter of agreement process when referring to Members to out-of-network providers. Responsible for timely and appropriate documentation in the medical management system. Assist with identifying potential cases for Case Management, Disease Management, Health Education and/or quality of care issues and making appropriate referrals when needed. Responsible for working with Team Members to support the goals of the department and the vision of the organization. Receive phone calls and assist with provider requests for authorization status updates, extensions, and modifications. Process all authorizations through Quick Cap managed care processing software. Required Experience Three (3) or more years of utilization management experience in a health care delivery setting. Preferred Experience Experience in an HMO, IPA, or Managed Care setting preferred. Education Qualifications High school diploma or GED required. Preferred Education Associates of Bachelor's degree. Professional Licenses Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN required. Knowledge Requirement Knowledge of Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements. ICD-9/10 and CPT coding. Knowledge of capitated managed care environment helpful. MediCal, Medicare and other state/federal Program & Regulations. Knowledge of division of financial responsibility (DOFR) contracts preferred. Knowledge of benefit plans preferred. Skills Requirement Computer skills required and proficiency in Windows applications preferred. Proficiency in Excel strongly preferred. Excellent communication and interpersonal skills. Strong organizational skills. Professional demeanor. Commitment to Team Culture. Working Conditions Must be able to sit, walk, and stand. Must be able to use hands and fingers to operate equipment including, but not limited to, computers, phones, and stationery. Must occasionally lift up to 25 pounds. Must be able to view screens and monitors 90% of the time while stationary. Work Environment We offer a hybrid work model, allowing employees to work in-office and remotely as agreed upon with management. About Golden Coast MSO Golden Coast MSO was founded to create a proactive, easy to work with management services organization. Seeing an opportunity to provide exceptional professional services, our team came together to design an MSO that prioritizes provider and patient needs. We are an expanding organization looking to build a team committed to excellence and professional growth. We value proactive and honest individuals who can create simple and effective systems which place patients' needs first.

Job Types:

Full-time, Part-time Pay:

$30.00 - $40.00 per hour

Benefits:

Health insurance Paid time off

Work Location:

Hybrid remote in Riverside, CA 92501