Medical Case Manager (LVN)
Apply NowCompany: CA_CalOptima_Utilization Management
Location: Orange, CA 92867
Description:
Details
Client Name
CA_CalOptima_Utilization Management
Job Type
Travel
Offering
Nursing
Profession
LPN/LVN
Specialty
LPN / LVN
Job ID
16136289
Job Title
Medical Case Manager (LVN)
Weekly Pay
$1862.06
Shift Details
Scheduled Hours
40
Job Order Details
Start Date
03/06/2025
End Date
05/31/2025
Duration
13 Week(s)
Job Description
Due Date - 03/06/2025
Summary: Temp position for Utilization Management - Pre-Authorization Nurse Reviewer support.
Description:
CalOptima Health is seeking a highly motivated an experienced TEMPORARY - Medical Case Manager (LVN) (Pre-Authorization Nurse Reviewer) to join our team. 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 Information:
Department: Utilization Management
Salary Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947)
Work Arrangement: Full Office
Work Schedule: Thursday to Monday (7:30 a.m. to 4:30 p.m.)
Submission Information:
The deadline to be guaranteed full review of your submission is due by Thursday, March 6, 2025 by 9:00 p.m. PST. This position will remain open for a minimum of seven (7) days, but may be extended if a lack of qualified applicants are received or if we are hiring multiple positions.
Duties & Responsibilities:
85% - Medical Review Support
oParticipates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
oAssists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
oReviews requests for medical appropriateness.
oVerifies 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.
oScreens 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.
oCompletes required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates.
oReviews 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.
oContacts the health networks and/or CalOptima Health's Customer Service department regarding health network enrollments.
oIdentifies and reports any complaints to the immediate supervisor utilizing the call tracking system or verbal communication if the issue is urgent.
oRefers cases of possible over/under utilization to the Medical Director for proper reporting.
oMeets productivity and quality of work standards on an ongoing basis.
10% - Administrative Support
oAssists the manager with identifying areas of staff training needs and maintains current data resources.
5% - Completes other projects and duties as assigned.
Minimum Qualifications:
High School diploma or equivalent required PLUS 3 years of nursing experience required, 1 year of which must be as a Clinical Nurse Reviewer; 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.
1 year of utilization management/prior authorization review experience required.
Preferred Qualifications:
Active Certified Case Manager (CCM) certification.
Managed care experience.
Required Licensure / Certifications:
Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California required.
Knowledge & Abilities:
Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
Work independently and exercise sound judgment.
Communicate clearly and concisely, both orally and in writing.
Work a flexible schedule; available to participate in evening and weekend events.
Organize, be analytical, problem-solve and possess project management skills.
Work in a fast-paced environment and in an efficient manner.
Manage multiple projects and identify opportunities for internal and external collaboration.
Motivate and lead multi-program teams and external committees/coalitions.
Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Physical Requirements (With or Without Accommodations):
Ability to visually read information from computer screens, forms and other printed materials and information.
Ability to speak (enunciate) clearly in conversation and general communication.
Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
Lifting and moving objects, patients and/or equipment 10 to 25 pounds
Work Environment:
If located at the 500, 505 Building or a remote work location:
Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
There are no harmful environmental conditions present for this job.
The noise level in this work environment is usually moderate.
If located at PACE:
Work is typically indoors in a clinical setting serving the frail and elderly.
There may be harmful or hazardous environmental conditions present for this job.
The noise level in this work environment is usually moderate to loud.
If located in the Community:
Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
Employee will occasionally work outdoors in varied temperatures.
There may be harmful or hazardous environmental conditions present for this job.
The noise level in this work environment is usually moderate to loud.
Client Details
Address
505 City Parkway West
City
Orange
State
CA
Zip Code
92868
Client Name
CA_CalOptima_Utilization Management
Job Type
Travel
Offering
Nursing
Profession
LPN/LVN
Specialty
LPN / LVN
Job ID
16136289
Job Title
Medical Case Manager (LVN)
Weekly Pay
$1862.06
Shift Details
Scheduled Hours
40
Job Order Details
Start Date
03/06/2025
End Date
05/31/2025
Duration
13 Week(s)
Job Description
Due Date - 03/06/2025
Summary: Temp position for Utilization Management - Pre-Authorization Nurse Reviewer support.
Description:
CalOptima Health is seeking a highly motivated an experienced TEMPORARY - Medical Case Manager (LVN) (Pre-Authorization Nurse Reviewer) to join our team. 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 Information:
Department: Utilization Management
Salary Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947)
Work Arrangement: Full Office
Work Schedule: Thursday to Monday (7:30 a.m. to 4:30 p.m.)
Submission Information:
The deadline to be guaranteed full review of your submission is due by Thursday, March 6, 2025 by 9:00 p.m. PST. This position will remain open for a minimum of seven (7) days, but may be extended if a lack of qualified applicants are received or if we are hiring multiple positions.
Duties & Responsibilities:
85% - Medical Review Support
oParticipates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
oAssists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
oReviews requests for medical appropriateness.
oVerifies 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.
oScreens 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.
oCompletes required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates.
oReviews 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.
oContacts the health networks and/or CalOptima Health's Customer Service department regarding health network enrollments.
oIdentifies and reports any complaints to the immediate supervisor utilizing the call tracking system or verbal communication if the issue is urgent.
oRefers cases of possible over/under utilization to the Medical Director for proper reporting.
oMeets productivity and quality of work standards on an ongoing basis.
10% - Administrative Support
oAssists the manager with identifying areas of staff training needs and maintains current data resources.
5% - Completes other projects and duties as assigned.
Minimum Qualifications:
High School diploma or equivalent required PLUS 3 years of nursing experience required, 1 year of which must be as a Clinical Nurse Reviewer; 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.
1 year of utilization management/prior authorization review experience required.
Preferred Qualifications:
Active Certified Case Manager (CCM) certification.
Managed care experience.
Required Licensure / Certifications:
Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California required.
Knowledge & Abilities:
Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
Work independently and exercise sound judgment.
Communicate clearly and concisely, both orally and in writing.
Work a flexible schedule; available to participate in evening and weekend events.
Organize, be analytical, problem-solve and possess project management skills.
Work in a fast-paced environment and in an efficient manner.
Manage multiple projects and identify opportunities for internal and external collaboration.
Motivate and lead multi-program teams and external committees/coalitions.
Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Physical Requirements (With or Without Accommodations):
Ability to visually read information from computer screens, forms and other printed materials and information.
Ability to speak (enunciate) clearly in conversation and general communication.
Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
Lifting and moving objects, patients and/or equipment 10 to 25 pounds
Work Environment:
If located at the 500, 505 Building or a remote work location:
Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
There are no harmful environmental conditions present for this job.
The noise level in this work environment is usually moderate.
If located at PACE:
Work is typically indoors in a clinical setting serving the frail and elderly.
There may be harmful or hazardous environmental conditions present for this job.
The noise level in this work environment is usually moderate to loud.
If located in the Community:
Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
Employee will occasionally work outdoors in varied temperatures.
There may be harmful or hazardous environmental conditions present for this job.
The noise level in this work environment is usually moderate to loud.
Client Details
Address
505 City Parkway West
City
Orange
State
CA
Zip Code
92868