Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
The Utilization Management Nurse Specialist LVN II will facilitate, coordinate and approve medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or on site admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/ family interaction to develop and implement a successful discharge plan.
DutiesPromote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment.
Perform prospective, concurrent, post-service and retrospective claim medical review processes. Utilizing considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge and application of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies cases needing Physician Advisor (PA) review or input and presents for physician review if indicated.
Perform telephonic and/or on site admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate Inbound requests received from providers.
Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.
Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network.
Identify and initiates referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Ensure potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. Ensure high risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director.
Documents in platform/system of record. Utilizes designated software system to document reviews and or notes.
Participate in the department's continuous quality improvement activities. Communicates to UM Manager and supervising RN, barriers to completing assignments or daily work in an efficient and effective manner.Receive incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner.
Perform other duties as assigned.
Education RequiredAssociate's Degree
Education PreferredBachelor's Degree
ExperienceRequired: At least 4 years of experience in a patient care setting and/or combination in utilization management, appeals and grievances, delegation oversight, and/or CNA experience.
At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting.
Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business.
SkillsRequired: Technical skills: Must be computer literate, with expertise in Outlook, Word, Excel, and PowerPoint. Effectively utilize computer and appropriate software and interacts as needed with L.A. Care Information System.
Customer Service Skills: Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team.
Excellent time management and priority-setting skills.
Maintains strict member confidentiality and complies with all HIPAA requirements.
Strong verbal and written communication skills.
Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM.
Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM.
Licenses/Certifications RequiredLicensed Vocational Nurse (LVN) - Active, current and unrestricted California License
Licenses/Certifications PreferredCase Management Certificate
Required TrainingPhysical RequirementsLight
Additional InformationMay work on occasional weekends and some holidays depending on business needs.
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including Paid Time Off (PTO)Tuition ReimbursementRetirement PlansMedical, Dental and VisionWellness ProgramNearest Major Market: Los Angeles
Job Segment: LVN, Nursing, Medicare, Patient Care, Nursing Assistant, Healthcare
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