What are the responsibilities and job description for the Medical Case Manager (LVN - Concurrent Review) position at SUNSHINE ENTERPRISE USA LLC?
Job Description
Job Description
Company Overview : Our client is a leading healthcare located in Orange, CA, seeking a medical case manager for Concurrent Review with an Licensed Medical Nurse (LVN) background.
Position Summary : The successful candidate should hold a current, unrestricted 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.
Work Duration : up to 6 months
Work Schedule : Thursday ~ Monday
Work type : On-site with a possibility to Telework
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 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.
Requirements
Experience & Education :
Necessary Attributes :
Benefits
Competitive salary package
