Job Description

• Responsible for screening and reviewing prospective, concurrent, and retrospective referrals and authorizations for medical necessity and appropriateness of service and care and discussing with Medical Directors.

• Coordinates health care services with appropriate physicians, facilities, contracted providers, ancillary providers, allied health professionals, funding sources, and community resources.
• Responsible for the prospective review to determine the appropriateness of denial, possible alternative treatment, and draft denial language to ensure consistent application of standardized, nationally recognized UM criteria and appropriate use of denial language.
• Coordinates out-of-network and out-of-area cases with members' health plans and the Case Management team.
• Reviews patient referrals within the specified care management policy timeframe (Type and Timeline Policy).
• Develops and maintains effective working relationships with physicians and office staff
• Demonstrates a thorough understands of the cost consequences resulting from care management decisions through the utilization of appropriate reports such as Health Plan Eligibility and Benefits and Division of Responsibility (DOR)
• Maintains effective communication with health plans, physicians, hospitals, extended care facilities, patients, and families.

Competency Requirements:

• Graduation from an accredited Licensed Vocational Nurse program
• Active, unrestricted LVN license in the state of California
• 1+ years of clinical experience working as an LVN/LPN
• 1+ years Utilization management experience including Prior Authorization

• 3+ years of experience working as an LVN/LPN
• 2+ years of previous care management, utilization review or discharge planning experience.
• Experience in an HMO or experience in a Managed Care setting

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