Title: TEMP - Medical Case Manager (LVN) (3) Location: Orange CA 92868 Duration: 5 months Full Office Duties & Responsibilities: 85% - Medical Review Support Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.

• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Reviews requests for medical appropriateness.

• Verifies 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.

• Screens 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.

• Completes required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates.

• Reviews 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.

• Contacts the health networks and/or * Health’s Customer Service department regarding health network enrollments.

• Identifies and reports any complaints to the immediate supervisor utilizing the call tracking system or verbal communication if the issue is urgent.

• Refers cases of possible over/under utilization to the Medical Director for proper reporting. Meets productivity and quality of work standards on an ongoing basis. 10% - Administrative Support Assists 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. 3 years of nursing experience required, 1 year of which must be as a Clinical Nurse Reviewer. 1 year of utilization management/prior authorization review experience required. 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.

  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 * Health's leadership and staff and external contacts at all levels and with diverse backgrounds.

• 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.