Utilization Management Nurse, Lvn

Utilization Management Nurse, Lvn


Utilization Management Nurse, Lvn

Details of the offer

Job Requisition ID: 3755 Position Summary/Position 13; Under the general direction of the Utilization Management Clinical Manager and Supervisor, and within the LVN scope of practice, the incumbent is responsible for working directly with Providers, contracted entities and vendors to ensure coordinated, continuous cost effective quality healthcare for IEHP Members.

Major Functions (Duties and Responsibilities) 13;

1. Responsible for gathering of clinical documentation to assist the R.N. Letter Review Nurse and Medical Director with decision of prospective/pre:service, concurrent or retrospective reviews based on clinical criteria for appropriateness of outpatient services and care.
2. Works collaboratively with the UM clinical team to ensure regulatory timeframes are upheld for authorization of concurrent, outpatient or ancillary services as per approved clinical criteria, including but not limited to, outpatient surgery, durable medical equipment, home health, etc.
3. Serves as a resource for IEHP Member and Provider Service departments for outpatient utilization management, referral, and continuity of care issues.
4. Works with Contracts Department to identify gaps in provider network.
5. Responsible for assisting with the letter of agreement process when referring to Members to out:of:network providers.
6. Responsible for timely and appropriate documentation in the medical management system.
7. Assist with identifying potential cases for Case Management, Disease Management, Health Education and/or quality of care issues and making appropriate referrals when needed.
8. Assist with identifying alternate payer sources such as CCS, IRC, etc.
9. Responsible for working with Team Members to support the goals of the department and the vision of the organization.

Supervisory Responsibilities 13;

Leading: Self

Experience Qualifications 13;

Two (2) or more years of utilization management experience in a health care delivery setting.

Preferred Experience 13;

Experience in an HMO or experience in a Managed Care setting preferred.

Education Qualifications 13;

High school diploma or GED required.

Preferred Education 13;
Professional Certification 13;
Professional Licenses 13;

Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN required.

Drivers License Required 13;

Yes, must have a valid California Drivers License.

Knowledge Requirement 13;

Knowledge of Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements. ICD:9/10 and CPT coding. Knowledge of capitated managed care environment helpful. MediCal, Medicare and other state/federal Program and Regulations.

Skills 13;
Abilities Requirement 13;

Professional demeanor.

Commitment to Team Culture 13;

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions 13;

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Physical Requirements 13;

Starting Salary:

49,192.00 :

Pay rate will commensurate with experience

Inland Empire Health Plan (IEHP) is the largest not:for:profit Medi:Cal and Medicare health plan in the Inland Em

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