Job Description

Company Overview:   Our client is a leading healthcare located in Orange, CA, seeking a medical case manager for Concurrent Review with an Licensed Medical Nurse (LVN) background.

Position Summary:   The successful candidate should hold a current, unrestricted LVN license with 3 years of nursing experience, 1 year as a Clinical Nurse Reviewer along with 1 year of utilization management/prior authorization review experience.

Work Duration:   up to 6 months

Work Schedule:   Thursday ~ Monday

Work type:   On-site with a possibility to Telework

Position Responsibilities:

• Review requests for medical appropriateness using established clinical protocols.
  
• Verify and process specialty referrals, diagnostic testing, outpatient procedures, home health care services, and durable medical equipment via telephone or fax.
  
• Screen requests for review by the Medical Director, gather necessary medical information, communicate decisions, and document outcomes in the utilization management system.
  
• Ensure accurate coding (ICD-10, CPT-4, HCPCS) and coverage verification specific to Health’s line of business.
  
• Address health network enrollments and liaise with Customer Service regarding network-related issues.
  
• Identify and report complaints to supervisors and escalate over/under utilization cases to the Medical Director.
  
• Maintain productivity and quality standards consistently.
  
• Complete additional assignments and projects as assigned.
  
• Assist in identifying staff training needs and maintain updated data resources.
  

Requirements

Experience & Education:

• Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in California.
  
• High School diploma or equivalent required.
  
• 3 years of nursing experience, including 1 year as a Clinical Nurse Reviewer
  
• 1 year of Concurrent Review (in-patient) experience required
  

Necessary Attributes:

• Establish effective relationships with internal and external stakeholders.
  
• Demonstrate independent judgment and decision-making skills.
  
• Communicate effectively both verbally and in writing.
  
• Flexible schedule availability for evening and weekend events.
  
• Strong organizational, analytical, and problem-solving abilities.
  
• Proficiency in Microsoft Office (Word, Outlook, Excel, PowerPoint) and job-specific applications/systems
  

Benefits

Competitive salary package

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