LVN Case Management

Bakersfield Family Medical Group; Bakersfield (CA); On-site; USD 42,000 - 49,000; Full time

Job summary

Bakersfield Family Medical Group seeks an LVN Case Manager to review referrals for ambulatory care, elective inpatient services, and durable medical equipment under Utilization Management. You will work with the Medical Director and care teams to ensure evidence-based, compliant decisions and maintain strong provider relationships.

The role emphasizes successful handling of denials, rapid response to questions, and collaboration across departments, with annual compliance trainings and patient

Qualifications

• Knowledge of health plan and CMS regulations and guidelines.
• Experience coordinating utilization management referrals and denials.
• Ability to communicate with physicians, staff, and members professionally.

Responsibilities

• Coordinate the UM process per health-plan criteria.
• Obtain and document pertinent information for referrals.
• Serve as clinical liaison for UM with Medical Director and leadership.
• Maintain HIPAA compliance and patient safety.
• Review complex cases with Medical Director and UM leadership.
• Communicate with providers and patients about UM questions.
• Generate and analyze reports to monitor turn-around times.
• Assist in writing denial letters with Denial Coordinator.

Skills

HIPAA compliance

Clinical liaison

Communication

Detail oriented

Education

Graduate from an accredited school of Nursing

Valid State License as LVN

Three years acute hospital experience

Case management experience (recommended)

Tools

Crystal Reports

Job description

Under the direction of the Director of Utilization Management and Customer Service, this position is responsible to review all referrals for ambulatory care services, elective inpatient services, and durable medical equipment. This will be achieved using established criteria and Health Plan benefit guidelines in conjunction with the Medical Director and support staff in Utilization Management. The LVN Case Manager will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers.

• Coordinator the UM process in conjunction with criteria established by health plans, CMS, Milliman, InterQual and HPN Clinical Services.
• Obtain and document all pertinent information in regard to individual referrals utilizing pertinent guidelines established by the health plans, CMS, or nationally approved guidelines.
• Serve as clinical liaison for the Utilization Management Department brining necessary issues to the Medical Director and UM Management.
• Maintain patient safety and HIPAA guidelines.
• Coordinate, identify and review complex cases with Medical Director and Utilization Management leadership team.
• Available for direct communication with physicians or members in regard to questions regarding the Utilization Management process.
• Identify problems within the UM process and provide solutions.
• Maintain positive and team-oriented attitude for the benefit of staff morale.
• Maintain current and accurate knowledge of denial letters and the process that needs to be followed in regard to those letters.
• Promote and encourage teamwork and pride among staff members regarding Utilization Management functions and cultivate good interdepartmental relationships.
• Be aware of changes to Utilization Management Process and the possible effects on referral processing.
• Run Crystal Reports to show daily aging and work with Utilization Management staff to ensure daily compliance with turn-around times.
• Work with the Denial Coordinator in the writing of denial letters for our members.
• Collaborate with the Medical Director to ensure proper services are approved for our members.
• Communicate with Provider Relations regarding needs for Letters of Agreement when referrals are approved to non contracted providers.
• Communicate changes with provider referral patterns with Medical Director and Utilization Management leadership team.
• Work with Customer Service to handle patient and provider complaints.
• Attend staff meetings and in-service learning events.
• HPN Compliance training annually.
• Language and Cultural Linguistics training annually.
• Other duties as assigned.
• Serve as a liaison of the Utilization Management department to physician offices, processing staff and other departments as needed to ensure collaboration and encourage open discussion regarding the clinical aspects of the referral process. Including responding to messages within next business day.
• Have a complete understanding of established policy and procedure within Heritage Provider Network regarding the clinical authorization process and procedures.
• Follow and have a complete understanding of health plan and CMS regulations; pertaining to timely decision making, benefit and guideline/criteria hierarchy regulations.
• Responsible for daily processing of retro, prior authorization review and ensuring patient meet appropriate level of care based on appropriate evidence-based criteria.
• Demonstrate the ability to research the authorization and claims history.
• Compile and review of clinical based guidelines, criteria and/or benefit information prior to forwarding referral to the Chief Medical Officer for clinical review.
• Be compliant with HIPAA regulations and maintaining of patient confidentiality.
• Serve as a role model personifying a service driven perspective, promote and encourage teamwork and pride among staff members for the benefit of staff morale.
• Number of referrals done:
  • By the end of six months - forty-five referrals per day (average of two hundred and twenty-five per week)
  • By the end of twelve months - Fifty-five referrals per day (average of two hundred and seventy-five per week)

8.1 Graduate from an accredited school of Nursing

8.2 Valid State License as an LVN.

8.3 Three Years Acute Hospital Experience, Required.

8.4 Case Management experience, recommended.

The pay range for this position at commencement of employment is expected to be reasonably between $30.15 and $35.47. However, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled