LVN Case Management

BAKERSFIELD FAMILY MEDICAL GROUP, INC.; Bakersfield (CA); On-site; USD 42,000 - 49,000; Full time

Job summary

Bakersfield Family Medical Group, Inc. is looking for an LVN Case Manager to review referrals for ambulatory and inpatient services, aligning with health plan criteria and CMS guidelines.

You will collaborate with the Medical Director and Utilization Management leadership, ensuring timely decisions and maintaining confidentiality. The role requires an LVN license, 3 years acute hospital experience, and experience in case management is recommended.

Qualifications

• Graduate from an accredited school of Nursing.
• Valid State License as an LVN.
• Three years acute hospital experience, required.
• Case Management experience, recommended.

Responsibilities

• Review referrals for ambulatory care, elective inpatient services, and durable medical equipment using established criteria and Health Plan guidelines.
• Serve as clinical liaison for Utilization Management with Medical Director and UM Leadership.
• Maintain patient safety and HIPAA guidelines.
• Identify problems in the UM process and provide solutions.
• Collaborate with Physician Relations for Letters of Agreement when referrals are approved to non-contracted providers.
• Handle daily processing of retro, prior authorization review, ensuring proper level of care based on evidence-based criteria.

Skills

Nursing

Case Management

HIPAA

Communication

Education

Licensed Vocational Nurse (LVN)

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 HPNClinical 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 amongstaff 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)

Requirements

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.

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