Partial Telework LVN Case Manager – PACE Utilization

CalOptima; Orange (CA); Híbrido; USD 78.000 - 125.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Partial Telework

CalPERS pension

Generous PTO

Flexible scheduling

Tuition Reimbursement

Descripción de la vacante

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.

Formación

• 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.

Responsabilidades

• 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.

Conocimientos

Nursing experience

Nurse reviewer

CPR/First-Aid certification

Communication skills

Educación

High school diploma or equivalent

LVN license in California

Herramientas

Microsoft Office

Utilization management system

Descripción del empleo

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.