Utilization Review LVN (California resident only)

Position Description

The Utilization Review LVN is responsible for ensuring a collaborative process of assessment/problem identification, care plan development, facilitation of the care plan, care coordination, evaluation, and continuous monitoring of an assigned population of patients across care settings.

Education

• Associates Degree in Nursing

Licensure/Certification

• A current active LVN license issued by the California Board.

Experience

• Experience interpreting evidenced based guidelines (Interqual and/or Milliman criteria sets), health plan/client specific chronic care guidelines, and policies/procedures
• 1-year managed care experience preferred
• 1-year case management experience preferred

Job Skills

• Core Competencies: Ethics and Values, Customer Focus, Action-Oriented, Learning on the Fly, Manage/Measure Work, Drive for Results, Priority Setting, Timely Decision-Making, Organizing, Functional and Technical Skills
• Demonstrated ability to work together across professions and individuals to improve health outcomes.
• Computer Proficiency (MS Word, MS Excel, MS Outlook, Video Conferencing)
• Knowledge of NCQA, DMHC, and state requirements for case management, Clinical guidelines (MCG).

Essential Functions of Job

• Responsible for ensuring the accuracy of member eligibility verification, member benefit verification, and network utilization to ensure accurate authorization adjudication.
• Able to accurately navigate the client-based UM platform and accurately enter authorization request data
• Effectively prepares authorization request for next level of review; to include, appropriate request of additional information, pre-certification verification, clinical recommendation, and accurate network utilization
• Consistently meets or exceeds departmental production standards and quality standards.
• Compliant with turnaround timeframes for authorization adjudication and provider notification.
• Ensures appropriate escalation of concerns; to include, but not limited to, Contracting issues (LOA, MOU) or Quality/Access concerns.
• Appropriately identifies criteria used for clinical decision making.
• Accurately and timely generation of denial or modification communication based on next level review outcomes, when applicable
• Able to perform focused provider reviews based on identified over or under utilization of services when directed.
• Able to provide data in an actionable manner upon completion of focused provider reviews.
• Adheres to Desktop Procedures and UM Policies and Procedures
• Adheres to the client defined adjudication rules for UM Nurse Reviewer level of review
• All other duties as assigned

Job Type: Full-time

Pay: $25.00 - $30.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

Application Question(s):

• Have you been fully vaccinated (3 times or more) for COVID-19?
• Do you live commutable distance to our Ontario office?

License/Certification:

• CA LVN License (Required)

Work Location: Remote

Salary : $25 - $30