Medical Case Manager
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3-4years
Not Disclosed
Salary Not Disclosed
1 Vacancy
Job Description
Company Overview: Our client is a leading healthcare located in Orange CA seeking claims resolution specialist that largely focuses on customer service.
Position Summary: The successful candidate should have 3 years of nursing experience including 1 year as a Clinical Nurse Reviewer along with 1 year of utilization management/prior authorization review experience.
Position Responsibilities:
Review requests for medical appropriateness using established clinical protocols.
Verify and process specialty referrals diagnostic testing outpatient procedures home health care services and durable medical equipment via telephone or fax.
Screen requests for review by the Medical Director gather necessary medical information communicate decisions and document outcomes in the utilization management system.
Ensure accurate coding (ICD10 CPT4 HCPCS) and coverage verification specific to CalOptima Health s line of business.
Address health network enrollments and liaise with Customer Service regarding networkrelated issues.
Identify and report complaints to supervisors and escalate over/under utilization cases to the Medical Director.
Maintain productivity and quality standards consistently.
Complete additional assignments and projects as assigned.
Assist in identifying staff training needs and maintain updated data resources.
Experience & Education:
High School diploma or equivalent.
3 years of nursing experience including 1 year as a Clinical Nurse Reviewer.
1 year of utilization management/prior authorization review experience.
An equivalent combination of education and experience may be considered.
Active Certified Case Manager (CCM) certification preferred.
Managed care experience.
Current unrestricted Licensed Vocational Nurse (LVN) license to practice in California.
Necessary Attributes:
Establish effective relationships with internal and external stakeholders.
Demonstrate independent judgment and decisionmaking skills.
Communicate effectively both verbally and in writing.
Flexible schedule availability for evening and weekend events.
Strong organizational analytical and problemsolving abilities.
Proficiency in Microsoft Office (Word Outlook Excel PowerPoint) and jobspecific applications/systems.
High School diploma or equivalent. 3 years of nursing experience, including 1 year as a Clinical Nurse Reviewer. 1 year of utilization management/prior authorization review experience. Work collaboratively with a wide variety of stakeholders. Prepare concise and clear reports. Work with all levels of staff to identify and problem-solve contracted provider issues. Work independently with minimal supervision or guidance. 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: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Employment Type
Full Time
