LVN Case Manager – Utilization & Care Coordination

Big Future Music Group; Bakersfield, Northern (CA, KY); Hybrid; USD 42,000 - 49,000; Full time

Job summary

Heritage Provider Network is seeking a LVN Case Manager to review referrals for ambulatory care, elective inpatient services, and durable medical equipment while applying health plan criteria and CMS guidelines. You will collaborate with the Medical Director and UM leadership to ensure appropriate utilization management decisions.

The role requires an LVN license, at least three years in acute hospital care, and recommended case management experience.

Qualifications

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

Responsibilities

• Review referrals for ambulatory care services, elective inpatient services, and DME using established criteria and guidelines.
• Coordinate the UM process with plan criteria (CMS, InterQual, Milliman, HPNClinical Services).
• Serve as clinical liaison for the Utilization Management Department to Medical Director and UM leadership.
• Maintain patient safety and HIPAA compliance.
• Coordinate and review complex cases with Medical Director and UM leadership team.
• Communicate with physicians or members regarding the UM process and answer questions.
• Identify problems in the UM process and provide solutions.
• Collaborate with Denial Coordinator on denial letters and with provider relations for Letters of Agreement when referrals are approved.
• Attend staff meetings and required trainings; ensure timely responses and policy understanding.
• Be aware of changes to UM process and ensure compliance with turnaround times.

Skills

Nursing

Case Management

Education

LVN License

Job description

Heritage Provider Network is seeking a LVN Case Manager to review referrals for ambulatory care, elective inpatient services, and durable medical equipment while applying health plan criteria and CMS guidelines. You will collaborate with the Medical Director and UM leadership to ensure appropriate utilization management decisions.

The role requires an LVN license, at least three years in acute hospital care, and recommended case management experience.