Medical Case Manager (Concurrent Review)

Company Overview:

Sunshine Enterprise is an industry-leading Staffing and Recruitment Firm. Our clients are fortune 500 companies, high growth start-up companies, government, and private equity firms, and lead professional services firms. As a leading force in the business landscape, we take pride in bringing together great people and great organizations by fostering a work environment that values creativity, diversity, and growth. If you're ready to embark on a rewarding career journey with a company that prioritizes its employees, explore our current job opportunities below.

Job Summary:

The Medical Case Manager (LVN) will be responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities, and ancillary providers. The incumbent will be responsible for prior authorization and referral related processes, which includes online responsibilities as well as selecting off-line tasks. The incumbent will utilize medical criteria, policies, and procedures to authorize referral requests from medical professionals, clinical facilities, and ancillary providers. The incumbent will directly interact with provider callers and serve as a resource for their needs.

Position Responsibilities

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Reviews requests for medical appropriateness.
• Verifies and processes specialty referrals, diagnostic testing, outpatient procedures, home health care services and durable medical equipment and supplies via telephone or fax by using established clinical protocols to determine medical necessity.
• Screens requests for Medical Director review, gathers pertinent medical information before submission to the Medical Director, follows up with the requester by communicating the Medical Director’s decision and documents follow-up in the utilization management system.
• Completes required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates.
• Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business.
• Contacts the health networks and/or Customer Service department regarding health network enrollments.
• Identifies and reports any complaints to immediate supervisor by utilizing the call tracking system or through verbal communication if the issue is of an urgent nature.
• Refers cases of possible over/under utilization to the Medical Director for proper reporting.
• Meets productivity and quality of work standards on an ongoing basis.
• Assists the manager with identifying areas of staff training needs and maintains current data resources.
• Completes other projects and duties as assigned.

Possesses the Ability To:

• Have strong problem solving, organizational and time management skills along with the ability to work in a fast-paced environment.
• Travel to locations with frequency, as the employer determines is necessary or desirable, to meet business needs.
• Establish and maintain effective working relationships with CalOptima Health’s leadership and staff.
• Communicate clearly and concisely, both orally and in writing.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.

Experience & Education

• High School diploma or equivalent required.
• Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the State of California required.
• 3 years of nursing experience, with 1 year as a Clinical Nurse Reviewer, required.
• 1 year of utilization management/prior authorization review experience required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Preferred Qualifications

• Managed care experience.
• Active Certified Case Manager (CCM) certification.

Knowledge of:

• Guidelines and regulations relevant to utilization management.
• Medical Terminology.
• Medi-Cal and Medicare benefits and regulations.
• Current Procedural Terminology (CPT-4), International Classification of Diseases (ICD-10), and Healthcare Common Procedure Coding System (HCPCS) codes and continual updates to knowledge base regarding the codes.

At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization, and we are happy to offer the following benefits:

• Competitive pay & weekly paychecks
• Health, dental, vision, and life insurance
• 401(k) savings plan
• Awards and recognition programs
• Benefit eligibility is dependent on employment status.

SUNSHINE ENTERPRISE USA LLC is an Equal Opportunity Employer and does not discriminate based on race or ethnicity, religion, sex, national origin, age, veteran disability or genetic information or any other reason prohibited by law in employment.