Medical Management Specialist, LVN

🕒 June 2

🏄 California – Remote

🏄 California – Remote

💵 $30 - $44 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

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SCAN

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1977

⚕️ Healthcare Insurance

👥 B2C

Healthcare Insurance • B2C

SCAN is a mission-driven healthcare organization focused on reinventing aging by delivering evidence-based, patient-centered care and coverage for older adults. It operates an integrated portfolio including health insurance plans with innovative benefits, in-home and virtual primary care, support programs for caregivers and homebound older adults, and specialized services for vulnerable populations. SCAN also invests in and partners with companies that advance care models and resources to help older adults remain healthy and independent at home.

📋 Description

• Ensure necessary inpatient and outpatient care and other services are rendered to SCAN members at the right time, at the right level of care and at the right location, adhering to all Medical Management policies and procedures • Issues determinations within required regulatory timeframes • Collect all relevant information and apply nationally recognized, evidenced-based criteria and guidelines, including federal and state regulations and Medical Policy, to ensure necessary inpatient and outpatient items and services are provided with optimum outcomes and cost effectiveness, and according to DOFR and member eligibility • Escalate requests to Medical Director following established guidelines, including secondary review for requests that do not meet criteria • Manage complex medical cases by applying the essential activities of case management and utilization management including assessment, planning, implementation, coordination, advocating, monitoring, and evaluation • Prepare and deliver case presentations, participate in case rounds and interdisciplinary team meetings (IDT), and incorporate recommendations into member’s care plan • Assist members who require urgent and emergent medical and behavioral health services while outside the network or the SCAN service area, by working directly with members, caregivers, and providers to ensure the provision of quality, coordinated care • Authorize care and services needed for stabilization, and when appropriate, works to transition members and services back into the SCAN provider network • Facilitate safe and effective discharges from inpatient settings by communicating member needs and issues identified during the course of inpatient treatment to other members of the care team, including but not limited to Facility CM, SCAN Care Management staff, medical group case managers, and Primary Care Physicians (PCPs) • Make referrals to other clinical programs per established criteria • Address urgent member quality or access to care issues via the Quality of Care (QOC) process • Escalate barriers to work processes to the attention of the supervisor/manager • Maintain documentation and data entry requirements adhering to all Medical Management policies and procedures • Maintain telephone standards by answering and returning calls and correspondence adhering to all Medical Management policies and procedures • Build effective professional relationships with providers and other internal and external partners by using excellent verbal and written communication skills, developing trust, meeting timelines, respecting cultural differences, using active listening skills, and maintaining confidentiality • Maintain the member‘s right to privacy and protect SCAN operations by keeping information confidential • Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks, participating in professional societies

🎯 Requirements

• Graduation from an accredited school of Licensed Vocational Nursing or equivalent clinical experience • Current and active California Licensed Vocational Nurse is required • Certified Professional of Utilization Management (CPUM or CPUR) or other Medical Case Management certification is preferred, or willing to attain such certification with 2 years • 3+ years of experience in medical-surgical nursing • 3+ years of Utilization Management/Prior Authorization experience in a Managed Care medical group, IPA, or managed care setting • Knowledge of (California) managed care industry, Medicare/MediCal required • Knowledge of Federal and State healthcare mandates and regulations • Health plan and vendor contracting knowledge • Proficient in Microsoft Word, Excel, Outlook, and PowerPoint, required • Strong analytic and problem-solving skills, required • Strong verbal and written communication skills, required • Ability to multitask and work closely with department RNs • Ability to work well in a fast-paced and dynamic environment • ICD-9, HCPCS and CPT coding knowledge

🏖️ Benefits

• An annual employee bonus program • Robust Wellness Program • Generous paid-time-off (PTO) • Eleven paid holidays per year, plus 1 additional floating holiday, plus 1 birthday holiday • Excellent 401(k) Retirement Saving Plan with employer match • Robust employee recognition program • Tuition reimbursement • A work-life balance