Travel Nurse RN - Case Manager - $1,858 per week in Orange, CA at talent4health

CalOptima Health is seeking a highly motivated an experienced TEMP - Medical Case Manager (LVN) to join our team. The Medical Case Manager (LVN) (Concurrent Review) will be responsible for providing case management intervention on behalf of members with short term, stable and predictable courses of illnesses. The incumbent will be responsible for answering the medical appropriateness, quality and cost effectiveness of proposed hospital/medical/surgical services in accordance with established criteria. Position Information: - Department: Utilization Management - Salary Grade: 311 - $37.43 - $59.8947 - Work Arrangement: Full Office Duties & Responsibilities: - 95% - Program Support 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 using established clinical protocols to determine medical necessity. Screens requests for the Medical Director’s 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-ups 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 CalOptima Health’s Customer Service department regarding health network enrollments. Identifies and reports any complaints to the immediate supervisor utilizing the call tracking system or verbal communication if the issue is urgent. 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. - 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 using established clinical protocols to determine medical necessity. - Screens requests for the Medical Director’s 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-ups 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 CalOptima Health’s Customer Service department regarding health network enrollments. - Identifies and reports any complaints to the immediate supervisor utilizing the call tracking system or verbal communication if the issue is urgent. - 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. - 5% - Completes other projects and duties as assigned. Minimum Qualifications: - High School diploma or equivalent required. - 3 years of nursing experience required, 1 year of which must be as a nurse reviewer. - An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. Preferred Qualifications: - 1 year of Concurrent Review (in-patient) experience. Required Licensure / Certifications: - Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California required. Knowledge & Abilities: - Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. - Work independently and exercise sound judgment. - Communicate clearly and concisely, both orally and in writing. - Work a flexible schedule; available to participate in evening and weekend events. - Organize, be analytical, problem-solve and possess project management skills. - Work in a fast-paced environment and in an efficient manner. - Manage multiple projects and identify opportunities for internal and external collaboration. - Motivate and lead multi-program teams and external committees/coalitions. - 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. Physical Requirements (With or Without Accommodations): - Ability to visually read information from computer screens, forms and other printed materials and information. - Ability to speak (enunciate) clearly in conversation and general communication. - Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions. - Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting. - Lifting and moving objects, patients and/or equipment 10 to 25 pounds Work Environment: If located at the 500, 505 Building or a remote work location: - Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. - There are no harmful environmental conditions present for this job. - The noise level in this work environment is usually moderate. If located at PACE: - Work is typically indoors in a clinical setting serving the frail and elderly. - There may be harmful or hazardous environmental conditions present for this job. - The noise level in this work environment is usually moderate to loud. If located in the Community: - Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. - Employee will occasionally work outdoors in varied temperatures. - There may be harmful or hazardous environmental conditions present for this job. - The noise level in this work environment is usually moderate to loud. About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto — "Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County’s best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. 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