Case Manager (LVN) - Utilization Mgmt - Sharp System Services - Days - FT
Company: SHARP HEALTHCARE
Location: San Diego
Posted on: April 24, 2024
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Job Description:
HoursShift Start Time:8 AMShift End Time:5 PMAdditional Shift
Information:8 hour shifts - FT 1.0Weekend Requirements:No
WeekendsOn-Call Required:NoHourly Pay Range (Minimum - Midpoint -
Maximum):$31.495 - $40.639 - $49.783 -The stated pay scale reflects
the range that Sharp reasonably expects to pay for this
position.--- The actual pay rate and pay grade for this position
will be dependent on a variety of factors, including an applicant's
years of experience, unique skills and abilities, education,
alignment with similar internal candidates, marketplace factors,
other requirements for the position, and employer business
practices. - -
What You Will Do
The CMI performs clinical/medical necessity reviews and authorizes
medical services that meet medical criteria. The review of care is
region specific and consists of outpatient healthcare services on
pre-certification requests, outpatient procedures, outpatient
services, elective inpatient admissions, home health services,
genetic testing, orthotics, prosthetics and complex durable medical
equipment. The CM1 also facilitates referrals to providers or
vendors that are region specific while determining medical
necessity and appropriateness.
Required Qualifications
Preferred Qualifications
Essential Functions
Assesses requests for services by first reviewing the patient's
benefit under the health plan and the criteria of the health plan
as to whether that service is the service is covered.
Reviews for medical necessity and appropriateness of services/care
based on health plan members medical condition.
Authorizes the correct vendor to provide care services reviewing
risk matrix and health plan contracted vendor list.
Communicates the decisions to the appropriate persons and documents
per UM policy.
Apply MCG formerly known as Milliman Care Guidelines, Medicare,
Health plan and other approved criteria as authorized by SCMG
medical directors to medical information and authorized appropriate
services/care.
Consults with supervisor, team lead and/or medical director to
discuss requests/care inconsistent to criteria and determine the
appropriateness of service/care.
Works closely with the Care Coordinators to obtain necessary
information for clinical reviews for decision making.
Documents per department policy in IDX, etc.
Communicates decisions to the requesting provider, facility and
member within department's approved guidelines.
Communicate effectively, both orally and in writing, with all
levels of management, medical staff and patients.
Assist in conflict management and resolution as appropriate.
Manage time effectively by applying organizational, critical
thinking, analytical, patient care evaluation, and problem solving
techniques.
Identify and refer members to case management or quality management
as appropriate for utilization or quality issues while maintaining
department processes in compliance with the State and Federal
standards.
Reviews patients for multiple diagnoses, surgeries, age,
inpatient/skilled nursing facility admits, repeat same type
services for need for further management of health care.
When a patient is suspected of need for further management,
communicates this to the appropriate Case Management Program per UM
policy.
Gathers pertinent information to provide Case Management with
knowledge of patient and issues.
If patient is being managed by Case Management, discusses requests
for services prior to authorizing additional
services/care.
Keeps current knowledge and understanding of applicable
accreditation and regulatory statutes related to health care,
managed care, case management practice.
Serves as a resource and mentor to regional team and other
department staff.
Establish mutually derived annual goals and meet goals.
Maintain individual in-service/performance records.
Attends and actively participates in department/team
process/quality improvement activities.
Authorizes medical care/services within specified turnaround times
when pertinent information is available. Maintains turn-around time
for routine, urgent and expedited referrals as outlined in SCMG's
Utilization Management Plan.
Decisions will be communicated to the appropriate persons within
SCMG standards (TAT). If cases have been pended for additional
information and will not meet the TAT communicates that information
to the requesting physician/provider.
Documentation for reviews will occur as per policy IDX, etc.
Knowledge, Skills, and Abilities
Sharp HealthCare is an equal opportunity/affirmative action
employer. All qualified applicants will receive consideration for
employment without regard to race, religion, color, national
origin, gender, gender identity, sexual orientation, age, status as
a protected veteran, among other things, or status as a qualified
individual with disability or any other protected class
California Licensed Vocational Nurse (LVN) - CA Board of Vocational
Nursing & Psychiatric Technicians
Keywords: SHARP HEALTHCARE, National City , Case Manager (LVN) - Utilization Mgmt - Sharp System Services - Days - FT, Executive , San Diego, California
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