L.A. Care Health Plan
Utilization Management Nurse Specialist LVN II
L.A. Care Health Plan, Los Angeles, California, United States, 90079
Job Category: ClinicalLocation: Los Angeles, CA, US, 90017Position Type: Full TimeRequisition ID: 11225Salary Range:
$67,186.00 (Min.) - $87,342.00 (Mid.) - $107,498.00 (Max.)Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan, serving more than 2 million members in five health plans.Mission:
L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents.The Utilization Management Nurse Specialist LVN II will facilitate, coordinate, and approve medically necessary referrals that meet established criteria. Responsibilities include:Assuring timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status.Generating approval, modification, and denial communications, including member and provider notification of referral determination.Actively monitoring for admissions in any inpatient setting.Performing telephonic and/or on-site admission and concurrent review, collaborating with onsite staff, physicians, providers, and family to develop and implement a successful discharge plan.Working with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service, and retrospective claims medical review.Monitoring and overseeing the collection and transfer of data (medical records) and referral requests by Providers.Acting as a department resource for medical service requests/referral management.Receiving incoming calls from providers and professionally handling complex calls.Duties
Promote and support team engagements, programs, and activities to create and ensure a positive and productive workplace environment.Perform prospective, concurrent, post-service, and retrospective claim medical review processes using clinical judgment, independent analysis, and knowledge of medical policies.Facilitate/review requests for higher levels of care or skilled nursing/discharge planning needs.Identify and initiate referrals for appropriate members to L.A. Care programs or external community-based programs.Document in the platform/system of record.Participate in the department’s continuous quality improvement activities.Perform other duties as assigned.Education Required
Associate's DegreeEducation Preferred
Bachelor's DegreeExperience
Required:At least 4 years of experience in a patient care setting and/or a combination in utilization management, appeals, grievances, and/or CNA experience.At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting.Preferred:Managed Care experience performing UM and CM at a medical group or management services organization.Experience with Managed Medi-Cal, Medicare, and commercial lines of business.Skills
Required:Technical skills: Must be computer literate, with expertise in Outlook, Word, Excel, and PowerPoint.Customer Service Skills: Excellent customer service due to frequent communication with providers and other members of the interdisciplinary team.Excellent time management and priority-setting skills.Maintains strict member confidentiality and complies with all HIPAA requirements.Strong verbal and written communication skills.Preferred:Knowledge of NCQA requirements for Utilization Management or CM.Knowledge of DHCS or CMS requirements for health plan compliance with UM or CM.Licenses/Certifications Required
Licensed Vocational Nurse (LVN) - Active, current, and unrestricted California LicenseLicenses/Certifications Preferred
Case Management CertificatePhysical Requirements
LightAdditional Information
May work on occasional weekends and some holidays depending on business needs.Salary Range Disclaimer:
The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.L.A. Care offers a wide range of benefits includingPaid Time Off (PTO)Tuition ReimbursementRetirement PlansMedical, Dental and VisionWellness Program
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$67,186.00 (Min.) - $87,342.00 (Mid.) - $107,498.00 (Max.)Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan, serving more than 2 million members in five health plans.Mission:
L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents.The Utilization Management Nurse Specialist LVN II will facilitate, coordinate, and approve medically necessary referrals that meet established criteria. Responsibilities include:Assuring timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status.Generating approval, modification, and denial communications, including member and provider notification of referral determination.Actively monitoring for admissions in any inpatient setting.Performing telephonic and/or on-site admission and concurrent review, collaborating with onsite staff, physicians, providers, and family to develop and implement a successful discharge plan.Working with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service, and retrospective claims medical review.Monitoring and overseeing the collection and transfer of data (medical records) and referral requests by Providers.Acting as a department resource for medical service requests/referral management.Receiving incoming calls from providers and professionally handling complex calls.Duties
Promote and support team engagements, programs, and activities to create and ensure a positive and productive workplace environment.Perform prospective, concurrent, post-service, and retrospective claim medical review processes using clinical judgment, independent analysis, and knowledge of medical policies.Facilitate/review requests for higher levels of care or skilled nursing/discharge planning needs.Identify and initiate referrals for appropriate members to L.A. Care programs or external community-based programs.Document in the platform/system of record.Participate in the department’s continuous quality improvement activities.Perform other duties as assigned.Education Required
Associate's DegreeEducation Preferred
Bachelor's DegreeExperience
Required:At least 4 years of experience in a patient care setting and/or a combination in utilization management, appeals, grievances, and/or CNA experience.At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting.Preferred:Managed Care experience performing UM and CM at a medical group or management services organization.Experience with Managed Medi-Cal, Medicare, and commercial lines of business.Skills
Required:Technical skills: Must be computer literate, with expertise in Outlook, Word, Excel, and PowerPoint.Customer Service Skills: Excellent customer service due to frequent communication with providers and other members of the interdisciplinary team.Excellent time management and priority-setting skills.Maintains strict member confidentiality and complies with all HIPAA requirements.Strong verbal and written communication skills.Preferred:Knowledge of NCQA requirements for Utilization Management or CM.Knowledge of DHCS or CMS requirements for health plan compliance with UM or CM.Licenses/Certifications Required
Licensed Vocational Nurse (LVN) - Active, current, and unrestricted California LicenseLicenses/Certifications Preferred
Case Management CertificatePhysical Requirements
LightAdditional Information
May work on occasional weekends and some holidays depending on business needs.Salary Range Disclaimer:
The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.L.A. Care offers a wide range of benefits includingPaid Time Off (PTO)Tuition ReimbursementRetirement PlansMedical, Dental and VisionWellness Program
#J-18808-Ljbffr