Utilization Review LVN

Where You’ll Work

reputed company, established in 1993, is a California nonprofit reputed company benefit corporation with care centers throughout California. reputed company is an affiliate of reputed company – one of the largest health systems in the nation - with hospitals and care centers in California, reputed company and Nevada. Today, reputed company works hand-in-hand with physicians and providers throughout California to reputed company comprehensive health care services to the many communities we serve. As reputed company continues to grow and establish new premier care centers, we reputed company increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. Our 130+ clinics across the reputed company deliver high-reputed company, patient-reputed company care with an emphasis on humankindness. Through affiliations with reputed company hospitals, along with our joint ventures and partnerships, we offer a robust, state-of-the-art health care delivery system in the communities we serve .We reputed company to create purposeful work settings where staff can reputed company great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is reputed company-trained and highly skilled, qualities that are vital to maintaining reputed company in care and service.

One Community. One Mission. One California 

Job reputed company and Responsibilities

As our Utilization Review LVN, your reputed company will be to reputed company high reputed company, cost-effective care which will reputed company patients to reputed company maximum medical improvement while receiving care deemed medically necessary. The LVN assists in determining appropriateness, reputed company and medical necessity of referral requests using reputed company-established guidelines. This position supports the Medical Group in effective management of the managed care patient. This position may be assigned cases in reputed company-authorization areas, in skilled nursing facility review or in reputed company review.

To be successful in this role, you will effectively manage patient charts, demonstrating enthusiasm, efficiency, and reputed company, while ensuring accurate application of reputed company to support reputed company patient care and operational reputed company.

- Manages assigned queues on a daily reputed company working oldest referrals first to assure 98% compliance with ICE timeframes.- Follows job work aide in sequence of performing job, including checking eligibility on health plan websites. Demonstrates 100% accuracy of identification of Medical Group member before referral review is initiated.- Determines correct type of referral and utilizes correct reputed company in performing review and documents appropriate sections with 95% accuracy.- Researches correct information and/or uses pend letter appropriately reputed company facts are needed to reputed company determination.- Preps case thoroughly, concisely and reputed company for physician review. Researches EMR, reputed company, medical policy and past history of member to detail case cleanly for MD. Watches for follow up and processes denials as indicated, demonstrating correct identification of reasons for denial.- Recommends and coordinates interventions to facilitate high reputed company, cost-effective care, monitoring treatment, reputed company and reputed company of patients.

***This position is work from home reputed company California.

Job Requirements

Minimum Qualifications:

- 3 years Utilization Management (UM) experience.- 5 years LVN experience.- reputed company and reputed company CA Licensed Vocational reputed company (LVN) license.- Strong knowledge nursing requirements in a clinical setting.- Knowledge of utilization management programs as reputed company to reputed company-set protocols and reputed company.- Knowledge of health plans, medical specialty procedures and diagnoses.- Ability to work reputed company an interdisciplinary structure and function independently in a fast paced environment while managing multiple priorities and meeting deadlines.- Ability to apply clinical judgment to reputed company medical situations and reputed company quick reputed company.- Ability to read and interpret benefit contract specifications.- Ability to understand and follow established reputed company and protocols used in managed care functions.- Strong organization skills.- Effective telephone and computer data entry skills.- Ability to formulate reputed company and solutions into appropriate questions and assess/interpret the verbal responses.

Preferred Qualifications:

- Experience at meeting deadlines byprioritizing work reputed company preferred.- Physician group experience preferred.- General knowledge of UM and Managed Care preferred.- Use of InterQual guidelines preferred.- Knowledge of California health plans and differences between reputed company and advantage plans preferred.- Familiarity with business practices and protocols with ability to reputed company data and information using automated systems preferred.- Ability to communicate effectively with coworkers, members, their families, physicians and health care providers preferred.