Hours
Shift Start Time: 8 AM
Shift End Time: 5 PM
Additional Shift Information:
Weekend Requirements: No Weekends
On-Call Required: No
Hourly Pay Range (Minimum - Midpoint - Maximum): $31.495 - $40.639 - $49.783
The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.
What You Will Do
The CMI performs clinical/medical necessity reviews and authorizes medical services that meet medical criteria. The review of care is region specific and consists of outpatient healthcare services on pre-certification requests, outpatient procedures, outpatient services, elective inpatient admissions, home health services, genetic testing, orthotics, prosthetics and complex durable medical equipment. The CM1 also facilitates referrals to providers or vendors that are region specific while determining medical necessity and appropriateness.
Required Qualifications
2 Years Experience in a medical setting (i.e. office, hospital, SNF, medical clinic etc.)
California Licensed Vocational Nurse (LVN) - CA Board of Vocational Nursing & Psychiatric Technicians -REQUIRED
Preferred Qualifications
Experience in managed care
Essential Functions
Able to identify benefit coverage
Assesses requests for services by first reviewing the patient's benefit under the health plan and the criteria of the health plan as to whether that service is the service is covered.
Reviews for medical necessity and appropriateness of services/care based on health plan members medical condition.
Authorizes the correct vendor to provide care services reviewing risk matrix and health plan contracted vendor list.
Communicates the decisions to the appropriate persons and documents per UM policy.
Applies approved criteria to medical information
Apply MCG formerly known as Milliman Care Guidelines, Medicare, Health plan and other approved criteria as authorized by SCMG medical directors to medical information and authorized appropriate services/care.
Consults with supervisor, team lead and/or medical director to discuss requests/care inconsistent to criteria and determine the appropriateness of service/care.
Works closely with the Care Coordinators to obtain necessary information for clinical reviews for decision making.
Documents per department policy in IDX, etc.
Communicates decisions to the requesting provider, facility and member within department's approved guidelines.
Communication and time management
Communicate effectively, both orally and in writing, with all levels of management, medical staff and patients.
Assist in conflict management and resolution as appropriate.
Manage time effectively by applying organizational, critical thinking, analytical, patient care evaluation, and problem solving techniques.
Patient record analysis and recommendation
Identify and refer members to case management or quality management as appropriate for utilization or quality issues while maintaining department processes in compliance with the State and Federal standards.
Reviews patients for multiple diagnoses, surgeries, age, inpatient/skilled nursing facility admits, repeat same type services for need for further management of health care.
When a patient is suspected of need for further management, communicates this to the appropriate Case Management Program per UM policy.
Gathers pertinent information to provide Case Management with knowledge of patient and issues.
If patient is being managed by Case Management, discusses requests for services prior to authorizing additional services/care.
Professional development
Keeps current knowledge and understanding of applicable accreditation and regulatory statutes related to health care, managed care, case management practice.
Serves as a resource and mentor to regional team and other department staff.
Establish mutually derived annual goals and meet goals.
Maintain individual in-service/performance records.
Attends and actively participates in department/team process/quality improvement activities.
Referral management
Authorizes medical care/services within specified turnaround times when pertinent information is available. Maintains turn-around time for routine, urgent and expedited referrals as outlined in SCMG's Utilization Management Plan.
Decisions will be communicated to the appropriate persons within SCMG standards (TAT). If cases have been pended for additional information and will not meet the TAT communicates that information to the requesting physician/provider.
Documentation for reviews will occur as per policy IDX, etc.
Knowledge, Skills, and Abilities
Knowledge of medical terminology, healthcare finances, alternative care options, utilization management, health plan criteria, established criteria such as MCG formerly known as Milliman Care Guidelines and its applications required.
Knowledge nd work experience in managed care preferred.
Experience and knowledge of IDX modules and systems, proficient in use of ICD-10, CPT and HCPC coding systems required.
Proficient in typing and computer data entry (45 wpm).
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class
California Licensed Vocational Nurse (LVN) - CA Board of Vocational Nursing & Psychiatric Technicians