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Utilization Care Manager, LVN Job
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| Employer Name: |
SpiderID: 13139910 |
| Location: Rancho Cordova, California |
Date Posted: 12/23/2022 |
| Wage: Negotiable |
Category: Insurance |
| Job Code: 17002JV-2191 |
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Job Description:
 Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. Blue Shield of California's Mission is to ensure all Californians have access to high-quality care at an affordable price. Blue Shield is focused on improving health care delivery by working closely with providers and making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 4 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than $325 million to the Blue Shield of California Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution.
We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone.
Description:
Description:
- This position facilitates the delivery of appropriate benefits and healthcare information which promotes cost effective outcomes for the customers who use our services.
- Utilizes clinical skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations.
- Performs clinical data collection, first level determination approvals for prior authorization of services, inpatient, outpatient and/or ancillary services under the supervision of an RN.
- Refers complex cases to RN according to guidelines.
- Collects information to support the process of rendering appropriate medical necessity/benefit determinations.
- Identifies members for referral opportunities to integrate with other products, services and/or programs and informs RN.
- Utilizes clinical experience, criteria/guidelines, policies and procedures in support of making timely and accurate medical necessity/benefit determinations and documenting appropriately for RN/MD determination.
- After review of clinical information, refers cases to MD when member does not meet clinical criteria for medical necessity or Level of care per CareWebQI guidelines.
- Triages and prioritizes cases to send to RN staff to meet required turn-around times.
- Prepares and presents cases to Medical Director (MD) as required by law for medical necessity determination by summarizing clinical information when an OOS licensed RN is not available to make first level determination approval.
- Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.
- Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with Regulatory and accreditation standards.
- Cases may be considered complex when they are potential high cost cases or requiring large case review for level of care challenges, and Initially, close supervision by RN will be required until LVN can meet a minimum of 90% audit independently on cases reviewed.
Qualifications:
Education/Qualifications:
- California LVN unrestricted, active license
- Education, skills, knowledge and competencies as defined for the Utilization Management Nurse Associate Knowledge of NCQA and federal and state requirements highly desirable
- Proficient computer skills, use of Word and Outlook, Excel preferred
Minimum Experience Level:
- 2 years managed care experience preferred 2-3 years acute clinical experience required
- This is primarily office work Requires being seated for several hours a day
- The employee regularly communicates via telephone, computer and in writing
- Non-telecommuters can expect to work in a climate controlled environment with generally quiet noise levels
Job Criteria:
Start Date:
Position Type: Full-Time Permanent
Years of Experience Required:
Education Required:
Overnight Travel:
Vacation Time:
Contact Information:
| Contact Name: Blue Shield of California |
Company Type: |
| Company: Blue Shield of California |
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