Medical Case Manager (LVN) (Concurrent Review)
Job Description
Department(s): Utilization Management (Concurrent Review)
Reports to: Supervisor, Utilization Management (Concurrent Review)
FLSA status: Non-Exempt
Salary Grade: K - $70,000 - $114,268
Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on
Thursday, February 15, 2024 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. About CalOptima HealthAre you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you're looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health!
About the PositionThe 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.
Duties & Responsibilities: - 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.
- Analyzes requests with the objective of monitoring utilization of services, this includes medical appropriateness and identifying potential high cost, complex cases for out-patient case management intervention.
- Reviews and evaluates proposed services utilizing medical criteria and/or established policies and procedures.
- Determines the appropriate action for the service being requested for approval, modification or denial and refers to the Medical Director for review when necessary.
- Reviews inpatient setting requests to determine if surgery and/or medical care is appropriate.
- Identifies diagnosis and determines the need for continuing hospitalizations, monitors the inpatient length of stay as per established guidelines and professional judgment.
- Initiates contact with patient, family and treating physicians to obtain additional information or to introduce the role of case management as needed.
- Reviews short-term cases and conducts a thorough and objective assessment of the member's status, including physical, psychosocial and environmental.
- Develops, implements and monitors a care plan through the interdisciplinary team process in conjunction with the individual member and family in internal and external settings across the continuum of care.
- Provides cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.
- Assesses members' status and progress, if progress is static or regressive, determines reason and encourages appropriate referrals to out-patient case management or make appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
- Establishes means of communication and collaboration with other team members, physicians, community agencies and administrators.
- Prepares and maintains appropriate documentation of patient care and progress within the care plan.
- Acts as an advocate in the client's best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
- Collaborates with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem-solving complex cases.
- Documents clinical information into the case notes along with the rationale for all decisions in the Guiding Care system.
- Completes other projects and duties as assigned.
Experience & Education: - High School diploma or equivalent required.
- Current, unrestricted Licensed Vocational Nurse (LVN) to practice in the State of California required.
- 3 years of Nursing Experience, with 1 year experience in a Managed Care setting required.
- 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.
Physical Demands and Work EnvironmentThe physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Physical demands: While performing duties of job, employee may be required to move about the organization. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes or laptop case, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use, in meetings, face-to-face interaction and while presenting.
- Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures.
About our Benefits & Wellness options:At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.
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 employment 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. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. Job Location: Orange, California
Position Type:
To apply, visit
https://jobs.silkroad.com/CalOptima/Careers/jobs/4531
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