Utilization Management Coordinator (LVN Or RN Preferred)

Procare MSO, Inc. is a Management Services Organization that manages IPAs (Independent Physician Associations) in California. We currently manage IPAs with Medicaid HMO and Medicare HMO Members. We're seeking a Utilization Management Coordinator to join our team. RNs and LVNs are welcome to apply.

Job Responsibilities:

- Performs prospective, initial, concurrent and retrospective reviews for all requested services to include but not limited to the following: inpatient admissions, facility requests, durable medical equipment (DME) and outpatient and home health services

- Conducts Pre-certification of all elective admissions with the Health Plan or other certifying entity.

- Receives notification of admissions and maintains admission logs.

- Monitors level and quality of care of services being provided and approved.

- Evaluates and provides feedback as needed to treating physicians regarding a member's discharge and home care plans and available covered services including identifying alternative levels of care that may be covered

- Coordinates an interdisciplinary approach to support continuity of care. Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for members

- Actively participates in the discussion and notification processes that result from the clinical utilization reviews with facilities and service provider

- Maintains compliance with all Health Plan guidelines on the reporting of cases/surgeries.

- Understands Health Plan policies and procedures regarding pre-certification, benefits by health plan and preferred facilities within each plan.

- Performs inpatient utilization review and applies client guidelines as detailed in the client UM Plan for length of stay/admission criteria to approve initial and continued inpatient services including the application of MCG Clinical Criteria or other Clinical Criteria.

- Requests relevant clinical information and documents in operating system.

- Prepares and send Admission Notifications and Admission Certifications to Physicians and Hospitals.

- Determines level of care and place of service indicated based on medical information available.

- Facilitates transition of care /discharge planning of members.

- Arranges needed post discharge services such as; DME, Home Health, Skilled Nursing

- Coordinate complicated medical cases and retrospective requests with Medical Directors.

- Assist referral coordinators in medical determinations on referrals.

- Responsible for the early identification and assessment of members for potential inclusion in a comprehensive care coordination program. Refers members for care coordination accordingly

- Performs other related activities as assigned.

Qualifications:

- Licensed Registered Nurse or Licensed Vocational Nurse with active California License

- Experience in the application of evidence-based guidelines, such as MCG criteria (formerly Milliman Care Guidelines) and Medicare (CMS) Guidelines.

- 1-2 years utilization review and/or managed care experience preferred

- Strong computer skills in Microsoft Office Suite

- Strong communication and interpersonal skills

-Ability to effectively present medical information one-on-one and to small groups

- Great if you can speak another language too, like Spanish or Vietnamese.
Related keywords: utilization review nurse, registered nurse, rn, utilization review, nurse

Job Type: Full-time

Pay: $19.00 - $30.00 per hour

Benefits:

• Dental insurance
• Flexible schedule
• Health insurance
• Vision insurance

Schedule:

• Monday to Friday

License/Certification:

• LVN (Preferred)
• LPN (Preferred)

Work Location:

• One location

Benefit Conditions:

• Waiting period may apply
• Only full-time employees eligible

Work Remotely:

• Temporarily due to COVID-19