Medical Case Manager (LVN, Prior-Authorization)

Kinetic Personnel Group is currently recruiting for a Medical Case Manager for a Public Health Agency (government entity). This position will be based in Orange County. This 3 billion-dollar a year government public agency is renowned for its work in the community and being a great place to work.

This position is responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities, and ancillary providers. The incumbent will be responsible for prior authorization and referral related processes that includes on-line responsibilities as well as selected off-line tasks. Utilizes Public Health Plans medical criteria, policies, and procedures to authorize referral requests from medical professionals, clinical facilities, and ancillary providers. This position directly interacts with provider callers and serves as a resource for their needs.

Job duties:

• Reviews requests for medical appropriateness.
• 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.
• Screen requests for the Medical Director review, gathers pertinent medical information prior to submission to the Medical Director; follows up with the requester by communicating the 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 the telephone call of fax to include any authorization updates.
• Reviews ICD-10, CPT-4 and HCPCS codes for accuracy and existence of coverage specific to the line of business.
• Contacts the Health Networks and/or Health Plan Customer Service regarding health network enrollments.
• Identifies and reports any complaints to immediate supervisor utilizing the call tracking system, or through verbal communication if the issue is of urgent nature.
• Refers cases of possible over/under utilization to the Medical Director for proper reporting.
• Meets productivity and quality of work standards on an ongoing basis.
• Assists Manager with identifying areas of staff training needs and maintains current data resources.
• Other projects and duties as assigned.
• Have strong problem solving, organizational, and time management skills along with the ability to work in a fast-paced environment.
• Communicate clearly & concisely, both verbally and in writing.
• Travel to locations with frequency as the employer determines is necessary or desirable to meet its business needs.
• 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.
• In-office, 5 days a week work setting.

Requirements:

• Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the State of California required.
• 3 years of Nursing experience required.
• 1 year as a Clinical Nurse Reviewer required.
• 1 years of Utilization Management/ Prior Authorization Review experience required.
• Have access means of transportation for work away from the primary office approximately 5% of the time.
• Managed Care experience preferred.
• Active Certified Case Manager (CCM) certification preferred.

Job Types: Full-time, Temporary

Pay: $40.00 - $60.00 per hour

Expected hours: 40 per week