Equiliem
Medical Case or Utilization Manager (LVN)
Equiliem, Orange, California, United States, 92613
Seeking a highly motivated and experienced TEMP to join our team. The role involves providing case management intervention on behalf of members with short-term, stable, and predictable courses of illnesses. The incumbent will be responsible for assessing the medical appropriateness, quality, and cost-effectiveness of proposed hospital/medical/surgical services in accordance with established criteria.Position InformationDepartment:
Utilization ManagementWork Arrangement:
Full Office
Duties & Responsibilities
Participate in a mission-driven culture of high-quality performance, focusing on customer service, consistency, dignity, and accountability.Assist the team in carrying out department responsibilities and collaborate with others to support short- and long-term goals/priorities for the department.Review requests for medical appropriateness.Verify and process specialty referrals, diagnostic testing, outpatient procedures, home health care services, and durable medical equipment and supplies via telephone or fax using established clinical protocols to determine medical necessity.Screen requests for the Medical Director's review, gather pertinent medical information prior to submission to the Medical Director, follow up with the requester by communicating the Medical Director's decision, and document follow-ups in the utilization management system.Complete required documentation for data entry into the utilization management system at the time of the telephone call or fax, including any authorization updates.Review International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4), and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business.Identify and report any complaints to the immediate supervisor utilizing the call tracking system or verbal communication if the issue is urgent.Refer cases of possible over/under utilization to the Medical Director for proper reporting.Meet productivity and quality of work standards on an ongoing basis.Complete other projects and duties as assigned.
Minimum Qualifications
High School diploma or equivalent required.3 years of nursing experience required, 1 year of which must be as a nurse reviewer.An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position may also be qualifying.
Preferred Qualifications
1 year of Concurrent Review (in-patient) experience.
Required Licensure / Certifications
Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California required.
Knowledge & Abilities
Develop rapport and establish and maintain effective working relationships with leadership, staff, and external contacts at all levels and with diverse backgrounds.Work independently and exercise sound judgment.Communicate clearly and concisely, both orally and in writing.Work a flexible schedule; available to participate in evening and weekend events.Organize, be analytical, problem-solve, and possess project management skills.Work in a fast-paced environment and in an efficient manner.Manage multiple projects and identify opportunities for internal and external collaboration.Motivate and lead multi-program teams and external committees/coalitions.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.
About Equiliem HealthcareEquiliem Healthcare specializes in staffing clinical, non-clinical, and allied personnel. We excel in all levels, disciplines, and specialties within the healthcare spectrum. Our projects range from short to long-term local and travel assignments. Equiliem has been recognized as a certified small business enterprise. In addition, we are proud that we have earned the prestigious Joint Commission accreditation for staffing firms and have been awarded Best in Staffing 4 years running by our employees and client partners.Benefits Offered
Medical InsuranceVision & Dental insuranceLife Insurance401KCommuter BenefitsEmployee Discounts & RewardsPayroll Payment Options
Utilization ManagementWork Arrangement:
Full Office
Duties & Responsibilities
Participate in a mission-driven culture of high-quality performance, focusing on customer service, consistency, dignity, and accountability.Assist the team in carrying out department responsibilities and collaborate with others to support short- and long-term goals/priorities for the department.Review requests for medical appropriateness.Verify and process specialty referrals, diagnostic testing, outpatient procedures, home health care services, and durable medical equipment and supplies via telephone or fax using established clinical protocols to determine medical necessity.Screen requests for the Medical Director's review, gather pertinent medical information prior to submission to the Medical Director, follow up with the requester by communicating the Medical Director's decision, and document follow-ups in the utilization management system.Complete required documentation for data entry into the utilization management system at the time of the telephone call or fax, including any authorization updates.Review International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4), and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business.Identify and report any complaints to the immediate supervisor utilizing the call tracking system or verbal communication if the issue is urgent.Refer cases of possible over/under utilization to the Medical Director for proper reporting.Meet productivity and quality of work standards on an ongoing basis.Complete other projects and duties as assigned.
Minimum Qualifications
High School diploma or equivalent required.3 years of nursing experience required, 1 year of which must be as a nurse reviewer.An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position may also be qualifying.
Preferred Qualifications
1 year of Concurrent Review (in-patient) experience.
Required Licensure / Certifications
Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California required.
Knowledge & Abilities
Develop rapport and establish and maintain effective working relationships with leadership, staff, and external contacts at all levels and with diverse backgrounds.Work independently and exercise sound judgment.Communicate clearly and concisely, both orally and in writing.Work a flexible schedule; available to participate in evening and weekend events.Organize, be analytical, problem-solve, and possess project management skills.Work in a fast-paced environment and in an efficient manner.Manage multiple projects and identify opportunities for internal and external collaboration.Motivate and lead multi-program teams and external committees/coalitions.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.
About Equiliem HealthcareEquiliem Healthcare specializes in staffing clinical, non-clinical, and allied personnel. We excel in all levels, disciplines, and specialties within the healthcare spectrum. Our projects range from short to long-term local and travel assignments. Equiliem has been recognized as a certified small business enterprise. In addition, we are proud that we have earned the prestigious Joint Commission accreditation for staffing firms and have been awarded Best in Staffing 4 years running by our employees and client partners.Benefits Offered
Medical InsuranceVision & Dental insuranceLife Insurance401KCommuter BenefitsEmployee Discounts & RewardsPayroll Payment Options