The LVN Utilization Management Nurse (UM Nurse) will provide routine review of authorization requests from all lines of business using respective national/state, health plan, nationally recognized guidelines. Responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency with coverage guidelines. The UM Nurse determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.

Responsibilities

Responsible for the daily review and processing of referral authorizations in accordance to turnaround time (TAT) standards set by ICE/Health Plan

Works collaboratively with Hospitalists, hospital partners, and care teams to provide holistic patient care that is focused on high quality in a cost effective

Monitors ongoing services and their cost effectiveness; recommending changes to the plan as needed using clinical evidence-based criteria – Milliman, Interqual, CMS, National Recognized American Academy of Specific Specialty, Health Plan specific criteria.

Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making

Maintains up to date knowledge of rules and regulations governing utilization management processes;

Input data into the Medical Management system to ensure timeliness of referral processing.

Verifies member benefits and eligibility upon receipt of the treatment authorization request.

Ensure timely provider and member oral and written notification of referral decisions.

Coordinates with Medical Director or referral specialists for timely referral processing

Facilitates LOA processing by sending request to Provider Contracting for non-contracted providers or facilities, when applicable

Facilitates LOA processing with the Health Plan for non-contracted facilities

May be responsible for daily concurrent review, retro reviews, discharge planning, pre-certification/prior authorization request review and ensures patients meet appropriate level of care based on acceptable evidenced based criteria.

Develops a positive working relationship with internal and external customers

Perform additional duties as assigned.

Measurements of Success:

I. EXCEEDS PERFORMANCE REQUIREMENTS

Meets the established Performance & Productivity Targets for area (s) of accountability.

Managing multiple priorities, demonstrated by ease and productivity to transition between multiple tasks.

Measurement (s):

• Met target on 90% of the Department’s Performance Metrics as it relates to core job function.
• Exceeds targeted productivity standard

Qualifications

Must reside in CA

Current valid License as a Licensed Vocational Nurse in the state of CA.

Minimum of 2 years of managed care experience

Demonstrated ability to work with automated systems, including electronic medical records and MS Office products such as Word, Excel and Outlook.

Excellent customer service; ability to be an effective communicator

Knowledge of federal, state and other applicable standards for clinical practice for assigned area(s) of responsibility.

Ability to work collaboratively with diverse individuals and situations, including strong problem solving and conflict resolution skills.

Job Type: Full-time

Pay: $31.00 - $45.30 per hour

Benefits:

• 401(k)
• 403(b)
• 403(b) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid sick time
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Work setting:

• Outpatient

Experience:

• Nursing: 2 years (Required)
• Managed care: 2 years (Required)

License/Certification:

• LVN (Required)

Ability to Relocate:

• Los Angeles, CA 90027: Relocate before starting work (Required)

Work Location: In person