Medical Case Manager, Prior Auth, LVN - Leading Industry Pay

Title: Medical Case Manager Prior Auth, LVN

Duration: 6 months

Compensation: $33.65 - $54.93

Description: The Medical Case Manager (LVN) will be 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, which includes on-line responsibilities as well as selecting off-line tasks. The incumbent will utilize our clients medical criteria, policies and procedures to authorize referral requests from medical professionals, clinical facilities and ancillary providers. The incumbent will directly interact with provider callers and serve as a resource for their needs.

What You Will Do:

• 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.
• 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 requests for 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 and 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 or fax to include any authorization updates.
• Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business.
• Contacts the health networks and/or the Customer Service department regarding health network enrollments.
• Identifies and reports any complaints to immediate supervisor by utilizing the call tracking system or through verbal communication if the issue is of an 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 the manager with identifying areas of staff training needs and maintains current data resources.
• Completes other projects and duties as assigned.

You Will Be Successful If:

• You possess the ability to:
  • Have strong problem solving, organizational and time management skills along with the ability to work in a fast-paced environment.
  • Travel to locations with frequency, as the employer determines is necessary or desirable, to meet business needs.
  • Establish and maintain effective working relationships with leadership and staff.
  • Communicate clearly and concisely, both orally and in writing.
  • 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.
• You have knowledge of:
  • Current CPT-4, ICD-10, and HCPCS codes and continual updates to knowledge base regarding the codes
  • Medical Terminology
  • MediCal and Medicare benefits and regulations

What You Will Bring:

• Current and unrestricted LVN license to practice in CA
• 3+ years of nursing experience, 1 as a Clinical Nurse Reviewer
• 1+ year of utilization management or prior authorization review experience
• Previous experience in a managed care environment preferred
• Active Certified Case Manager Certification, preferred

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.

That's Impresiv!