Medical Case Manager (LVN) (PACE - Utilization Management)

CalOptima; Orange (CA); Hybrid; USD 78,000 - 125,000; Full time

Benefits offered by this job

Partial Telework

CalPERS pension

Generous PTO

Flexible scheduling

Tuition Reimbursement

Job summary

CalOptima in Orange, California seeks a Medical Case Manager (LVN) for the PACE-Utilization Management team to support member health through careful case review and collaboration with providers.

This role includes partial telework with in-office days in Orange, CA, and requires an LVN license in California; you will document actions in the UM system and help ensure medically appropriate care for our members.

Qualifications

• High school diploma plus 3 years of nursing experience, with 1 year as a nurse reviewer.
• CPR and First-Aid certification required or must be obtained within six months.
• Current unrestricted LVN license to practice in California.

Responsibilities

• Perform case management and assess medical necessity for inpatient and outpatient services.
• Verify specialty referrals, tests, procedures, and equipment using clinical protocols.
• Submit and document requests in the utilization management system and follow up on decisions.
• Review ICD-10, CPT-4, HCPCS codes for coverage specificity.
• Address denied claims and provider disputes to maintain partnerships.
• Maintain productivity and assist in staff training and data resources.

Skills

Nursing experience

Nurse reviewer

CPR/First-Aid certification

Communication skills

Education

High school diploma or equivalent

LVN license in California

Tools

Microsoft Office

Utilization management system

Job description

Medical Case Manager (LVN) (PACE - Utilization Management)

CalOptima

Join Us in this Amazing Opportunity

The Team You'll Join

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

More About the Opportunity

We are hoping you will join us as a Medical Case Manager (LVN) (PACE-Utilization Management) and help shape the future of healthcare where you'll be an integral part of our PACE- Clinic team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Partial Telework.

- If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

Your Contributions To the Team:

• 95% - Case Management
• 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 for inpatient and outpatient services utilizing medical criteria and/or established policies and procedures.
• Verifies and processes specialty referrals, diagnostic testing, outpatient procedures, home health care services and durable medical equipment and supplies via telephone or fax by using established clinical protocols to determine medical necessity.
• Screens inpatient and outpatient requests for the PACE Medical Director review, gathers pertinent medical information prior to submission to the PACE Medical Director; follows up with the requester by communicating the PACE Medical Director's decision; documents follow-up in the utilization management system.
• Completes required documentation for data entry into the utilization management system at the time of receipt to include any authorization updates.
• Reviews ICD-10, CPT-4, and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the PACE.
• Ensures all internal and external PACE authorizations are complete with CPT codes, notes and pertinent information.
• Reviews the appropriateness of retro authorizations for review and works with the PACE Medical Director for proper review and authorizations.
• Reviews and follows up on denied claims and provider disputes/appeals to ensure accuracy of information and maintain partnerships with our contracted specialty offices.
• Refers cases of possible over/under utilization to the PACE Medical Director for proper reporting and reviewing.
• Meets PACE productivity and quality of work standards on an ongoing basis.
• Assists the manager with identifying areas of need for staff training and maintains current data resources.
• 5% - Other
• Completes other projects and duties as assigned.

Do You Have What the Role Requires?

• High school diploma or equivalent PLUS 3 years of nursing experience, with 1 year as a nurse reviewer, required; 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.
• CPR and First-Aid Certification required or must be obtained within six (6) months of date of hire.

You'll Stand Out More If You Possess the Following:

• Managed care experience.
• Concurrent review experience.

What the Regulatory Agencies Need You to Possess?

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

Your Knowledge & Abilities to Bring to this Role:

• Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Your Physical Requirements (With or Without Accommodations):

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Ways We Are Here For You

• You'll enjoy competitive compensation for this role.
• Our current hiring range is: Pay Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947).
• The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.
• This position is approved for Partial Telework (**If the position is Telework, it is eligible in California only**)
• A https://www.caloptima.org/en/careers#benefits
• CalPERS pension program and additional retirement packages.
• Additional benefits and perks including:
• A generous PTO program
• A quality work life balance
• Various wellness programs
• Tuition Reimbursement
• Professional development opportunities
• Career development opportunities
• Flexible scheduling
• And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.

Our Work Environment:

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

Why Join Us?

We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.

Our Commitment to You

Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet.

We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process.

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at [phone] if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

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