Description:

LVNs without 1 year of case management experience will not be considered

As a part of the Utilization Management team the LVN Case Manager is a member of the Care Coordination team.

LVN Case Manager have a queue of cases based on patient's last names. All new referrals go into this queue after the clinical team authorizes them. Case Manager must know CMS criteria -- each Health plan has different criteria. Case volume varies each day 30-50 cases in the queue. Minimum expectation is to process 25 cases per day (but expected to process as many as possible with quality/accuracy). If their queue is 0-5 cases, they can access the main portal que to get new cases (records are not attached and they will have to request). They are only servicing patients in the Inland Empire. These are outpatient referrals.

- Plans for and ensures that all post discharge care is coordinated appropriately according to the needs of the patient and ensures continuity of care.

- Conducts prior authorization review on all services that require nurse review.

- Travels to various hospitals within established areas to conduct patient visits.

- Conducts inpatient and skilled nursing facility level-of-care review on a concurrent basis.

- Plans for and coordinates all discharges from inpatient and skilled nursing facilities.

- Makes outbound calls to patients according to case management queue assignment and case management policies and procedures

- Tracks barriers to appropriate inpatient and SNF utilization according to policy and procedure.

- Attends Utilization Management and/or Quality Management meetings as needed.

- Appropriately changes patient's case management status to complex case management or to routine case management based on assessment of patient's medical status changes and progression of goals utilizing complex/routine case management criteria.

Skills:

Utilization review, prior authorization, Care management, medicare, referral coordinator, utilization management, Case management, interqual, ncqa, ncqa standards

Top Skills Details:

Utilization review,prior authorization,Care management,medicare,referral coordinator,utilization management

Additional Skills & Qualifications:

Must Know CMS criteria.

Must have experience working with Provider Offices.

Must Have Utilization management Experience.

Must have knowledge of both MediCal and MediCare

Knowledge of IDX (their system) is a plus! The system is pretty easy to learn, but they must be computer competent

• High School Diploma/GED - High School Diploma or GED

• LVN: (must be a CA License)

• Bachelors of Science in Nursing or other clinical advanced degree preferred.

• Managed care experience preferred.

• Two years experienced working with a medical group or IPA preferred

- Knowledge of nursing processes, case management and continuity of care. Ability to apply criteria to identify appropriate level of care on all admissions and clearly document any research conducted and rationale of decisions made. Ability to identify care needs across the age continuum and according to principles of growth and development over the life span.

- Ability to apply appropriate business rules, medical guidelines and/or health plan benefits to authorization decision making. Knowledge of network and benefit limitations and ability to collaborate with stakeholders to find alternatives that meet patient needs and achieve positive outcomes. Knowledge of disease management strategies

Experience Level:

Intermediate Level

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

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