Description :

The client is seeking a highly motivated an experienced Temporary - Concurrent Nurse Reviewer (LVN) (Medical Case Manager (LVN)) to join the team. The Medical Case Manager (LVN) (Concurrent Review) will be responsible for providing case management intervention on behalf of members with short term, stable and predictable courses of illnesses. The incumbent will be responsible for answering the medical appropriateness, quality and cost effectiveness of proposed hospital/medical/surgical services in accordance with established criteria.

Responsibilities :

• Program 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 the client’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.
• 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 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.

Preferred Qualifications :

• 1 year of Concurrent Review (in-patient) experience.

Required Licensure / Certifications :

• Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California required.