What are the responsibilities and job description for the Medical Case Manager - Concurrent Review position at Sunshine Enterprise USA LLC?
Company Overview : Our client is a leading healthcare located in Orange, CA, seeking medical case manager for Concurrent Review.
Position Summary : The successful candidate should hold a current, unrestricted Licensed Medical Nurse (LVN) license with 3 years of nursing experience, 1 year as a Clinical Nurse Reviewer along with 1 year of utilization management / prior authorization review experience.
Position Responsibilities :
- Review requests for medical appropriateness using established clinical protocols.
- Verify and process specialty referrals, diagnostic testing, outpatient procedures, home health care services, and durable medical equipment via telephone or fax.
- Screen requests for review by the Medical Director, gather necessary medical information, communicate decisions, and document outcomes in the utilization management system.
- Ensure accurate coding (ICD-10, CPT-4, HCPCS) and coverage verification specific to CalOptima Health’s line of business.
- Address health network enrollments and liaise with Customer Service regarding network-related issues.
- Identify and report complaints to supervisors and escalate over / under utilization cases to the Medical Director.
- Maintain productivity and quality standards consistently.
- Complete additional assignments and projects as assigned.
- Assist in identifying staff training needs and maintain updated data resources.
Experience & Education :
Necessary Attributes :
Please see HR for information on physical demands and work environment of this job.
Sunshine Enterprise USA is an “Equal Opportunity Employer—Minorities, Females, Veterans and Disabled Persons”
PI259152101
