Lead Nurse Coordinator (LVN/RN)

Overview

Provides assistance with oversight during the daily operations of the outpatient review process.Participates in the training and mentoring of team members. Provides support, resources, anddirection to staff. Assists in determining appropriateness, quality, and medical necessity ofrequested service

Responsibilities

Essential Duties and Responsibilities▪ Oversees daily operation of the outpatient review process.▪ Provides direction and support, to staff concerning daily assignments.▪ Provides training in outpatient review to new hires.▪ Provides performance feedback to the UM Team Manager.▪ Participates in the interview process of new hires.▪ Evaluates appropriateness of care through interpretation of benefits as outlined in Title22, Medi-Cal Provider Manual, DMHC CMS regulatory requirements, using PHCpolicies and procedures, and InterQual criteria for each product line.▪ Documents and maintains patient-specific records in the appropriate data collectionsoftware system.▪ Assists in the refinement/improvement of the Health Services programs. Participates incontinuous process improvement endeavors.▪ Works with other PHC departments to resolve issues relating to authorization ofmedical services.▪ Participates in Inter-rater Reliability studies, reviewing medical records as assigned.▪ This position, in addition to their own case load, may require other reviewresponsibilities as deemed necessary to provide coverage.▪ Communicates regularly with the UM Team Manager and works collaboratively toresolve issues.▪ Seeks UM Team Manager assistance as needed while coordinating work, makingdecisions, and handling questions or problems.▪ Participates in special projects and assignments as required.

Qualifications

Education and ExperiencE

Licensed Vocational Nurse (LVN) or Registered Nurse (RN),with two (2) years of managed care (case management) experience; or equivalent combination of education and experience. General knowledge of managed care with emphasis in utilization and/or case management preferred.

Special Skills, Licenses and Certifications

Current California Licensed Vocational Nurse (LVN) or Registered Nurse (RN),knowledge of nursing requirements in a clinical setting. Knowledge ofutilization management programs as related to use of pre-set criteriaand protocols. Familiarity with business practices and protocols withability to access data and information using automated systems. Abilityto work within an interdisciplinary structure and functionindependently in a fast-paced environment while managing multiplepriorities and meeting deadlines. Strong organizational skills required.Effective telephone and computer data entry skills required. ValidCalifornia driver’s license and proof of current automobile insurancecompliant with PHC policy

Performance Based Competencies

Excellent written and verbal communication skills with ability to readand interpret benefit contract specifications. Ability to understand andfollow established criteria and protocols used in managed carefunctions. Ability to formulate ideas and solutions into appropriatequestions and assess/interpret the verbal responses. Ability to applyjudgment to complex medical situations and make quick decisions.Ability to communicate effectively with coworkers, members, theirfamilies, physicians, and health care providers.

Work Environment And Physical Demands

Ability to prioritize workload and function effectively with frequentinterruptions and direction from multiple team members. More than50% of work time is spent in front of a computer monitor. Must be ableto lift, move, or carry objects of varying size, weighing up to 10 lbs.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

LVN: $49.54 - $64.41

RN: $56.98 - $74.07

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

Salary : $50 - $64