What are the responsibilities and job description for the UM LVN Case Management position at BAKERSFIELD FAMILY MEDICAL GROUP, INC.?
Under the direction of the Director of Utilization Management and Customer Service, this position is responsible to review all referrals for ambulatory care services, elective inpatient services, and durable medical equipment. This will be achieved using established criteria and Health Plan benefit guidelines in conjunction with the Medical Director and support staff in Utilization Management. The LVN Case Manager will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers.
1.1 Coordinate the UM process in conjunction with criteria established by health plans, CMS, Milliman, lnterQual and HPN Clinical Services.
1.2 Obtain and document all pertinent information in regard to individual referrals utilizing pertinent guidelines established by the health plans, CMS, or nationally approved guidelines.
1.3 Serve as clinical liaison for the Utilization Management Department brining necessary issues to the Medical Director and UM Management.
1.4 Coordinate, identify and review complex cases with Medical Director and Utilization Management leadership team.
1.5 Available for direct communication with physicians or members in regard to questions regarding the Utilization Management process.
1.6 Identify problems within the UM process and provide solutions.
1.7 Maintain positive and team-oriented attitude for the benefit of staff morale.
1.8 Promote and encourage teamwork and pride among staff members regarding Utilization Management functions and cultivate good interdepartmental relationships.
1.9 Be aware of changes to Utilization Management Process and the possible effects on referral processing.
1.10 Run Crystal Reports to show daily aging and work with Utilization Management staff to ensure daily compliance with turn-around times.
1.11 Work with the Denial Coordinator in the writing of denial letters for our members.
1.12 Collaborate with the Medical Director to ensure proper services are approved for our members.
1.13 Communicate with Provider Relations regarding needs for Letters of Agreement when referrals are approved to non- contracted providers.
1.14 Communicate changes with provider referral patterns with Medical Director and Utilization Management leadership team.
1.15 Work with Customer Service to handle patient and provider complaints.
1.16 Attend staff meetings and in-service learning events.
1.17 Serve as a liaison of the Utilization Management department to physician offices, processing staff and other departments as needed to ensure collaboration and encourage open discussion regarding the clinical aspects of the referral process. Including responding to messages within the next business day.
1.18 Have a complete understanding of established policy and procedure within Heritage Provider Network regarding the clinical authorization process and procedures.
1.19 Follow and have a complete understanding of health plan and CMS regulations, pertaining to timely decision making, benefit and guideline/criteria hierarchy regulations.
1.20 Responsible for daily processing of retro, prior authorization review and ensuring patient meet appropriate level of care based on appropriate evidence-based criteria.
1.21 Demonstrate the ability to research the authorization and claims history.
1.22 Compile and review of clinical based guidelines, criteria and/or benefit information prior to forwarding referral to the Chief Medical Officer for clinical review.
1.23 Serve as a role model personifying a service driven perspective, promote and encourage teamwork and pride among staff members for the benefit of staff morale.
1.24 Be compliant with HIPAA regulations and maintaining of patient confidentiality.
1.25 HPN Compliance training annually.
1.26 Language and Cultural Linguistics training annually.
1.27 This position qualifies for full remote option.
1.28 Other duties as assigned.
Requirements:
8.1 Graduate from an accredited school of Nursing.
8.2 Current valid CA License as an Licensed Vocation Nurse, required.
8.3 Three years acute hospital experience, required.
8.4 Case Management experience, recommended.
The pay range for this position at commencement of employment is expected to be between $30.15 and $35.47. However, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience.
If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
Compensation: Between $30.15 and $35.47
1.1 Coordinate the UM process in conjunction with criteria established by health plans, CMS, Milliman, lnterQual and HPN Clinical Services.
1.2 Obtain and document all pertinent information in regard to individual referrals utilizing pertinent guidelines established by the health plans, CMS, or nationally approved guidelines.
1.3 Serve as clinical liaison for the Utilization Management Department brining necessary issues to the Medical Director and UM Management.
1.4 Coordinate, identify and review complex cases with Medical Director and Utilization Management leadership team.
1.5 Available for direct communication with physicians or members in regard to questions regarding the Utilization Management process.
1.6 Identify problems within the UM process and provide solutions.
1.7 Maintain positive and team-oriented attitude for the benefit of staff morale.
1.8 Promote and encourage teamwork and pride among staff members regarding Utilization Management functions and cultivate good interdepartmental relationships.
1.9 Be aware of changes to Utilization Management Process and the possible effects on referral processing.
1.10 Run Crystal Reports to show daily aging and work with Utilization Management staff to ensure daily compliance with turn-around times.
1.11 Work with the Denial Coordinator in the writing of denial letters for our members.
1.12 Collaborate with the Medical Director to ensure proper services are approved for our members.
1.13 Communicate with Provider Relations regarding needs for Letters of Agreement when referrals are approved to non- contracted providers.
1.14 Communicate changes with provider referral patterns with Medical Director and Utilization Management leadership team.
1.15 Work with Customer Service to handle patient and provider complaints.
1.16 Attend staff meetings and in-service learning events.
1.17 Serve as a liaison of the Utilization Management department to physician offices, processing staff and other departments as needed to ensure collaboration and encourage open discussion regarding the clinical aspects of the referral process. Including responding to messages within the next business day.
1.18 Have a complete understanding of established policy and procedure within Heritage Provider Network regarding the clinical authorization process and procedures.
1.19 Follow and have a complete understanding of health plan and CMS regulations, pertaining to timely decision making, benefit and guideline/criteria hierarchy regulations.
1.20 Responsible for daily processing of retro, prior authorization review and ensuring patient meet appropriate level of care based on appropriate evidence-based criteria.
1.21 Demonstrate the ability to research the authorization and claims history.
1.22 Compile and review of clinical based guidelines, criteria and/or benefit information prior to forwarding referral to the Chief Medical Officer for clinical review.
1.23 Serve as a role model personifying a service driven perspective, promote and encourage teamwork and pride among staff members for the benefit of staff morale.
1.24 Be compliant with HIPAA regulations and maintaining of patient confidentiality.
1.25 HPN Compliance training annually.
1.26 Language and Cultural Linguistics training annually.
1.27 This position qualifies for full remote option.
1.28 Other duties as assigned.
Requirements:
8.1 Graduate from an accredited school of Nursing.
8.2 Current valid CA License as an Licensed Vocation Nurse, required.
8.3 Three years acute hospital experience, required.
8.4 Case Management experience, recommended.
The pay range for this position at commencement of employment is expected to be between $30.15 and $35.47. However, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience.
If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
Compensation: Between $30.15 and $35.47
Salary : $30 - $35
