Medical Case Manager (LVN)

Job Summary
The Medical Case Manager (LVN) (Pre-Authorization Nurse Reviewer) 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, including on-line responsibilities and select off-line tasks. The incumbent will utilize CalOptima Health’s 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:
85% - Medical Review Support

• 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 using established clinical protocols to determine medical necessity.
• Screens requests for the Medical Director’s review, gathers pertinent medical information prior to submission to the Medical Director, follows up with the requester by communicating the Medical Director’s decision and documents follow-ups 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 CalOptima Health’s Customer Service department regarding health network enrollments.
• Identifies and reports any complaints to the immediate supervisor utilizing the call tracking system or verbal communication if the issue is urgent.
• 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.

10% - Administrative Support

• Assists the manager with identifying areas of staff training needs and maintains current data resources.

5% - Other

• Completes other projects and duties as assigned.

Possesses the Ability to:

• Demonstrate strong problem solving, organizational and time management skills along with the ability to work in a fast-paced environment.
• 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: Excel, Outlook, PowerPoint, Word) 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 required, 1 year of which must be as a nurse reviewer.
• 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 may also be qualifying.

Preferred Qualifications

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

Knowledge of:

• Current CPT-4, ICD-10 and HCPCS codes and continual updates to knowledge base regarding the codes.
• Medical terminology.
• Medi-Cal and Medicare benefits and regulations.

Physical Demands and Work Environment
The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Physical demands: While performing duties of job, employee may be required to move about the organization. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes or laptop case, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use, in meetings, face-to-face interaction and while presenting.

• Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures.