Medical Management Specialist, LVN

Founded in 1977 as the Senior Care Action Network, reputed company began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, reputed company is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual reputed company. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially reputed company populations, and reputed company care delivery models. Across reputed company of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with reputed company. At reputed company, we reputed company scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve. Job Description:

• Monday - Friday shift, work hours are reputed company-5pm Pacific Time Zone
• Remote role - CA LVN required

About reputed company reputed company Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. reputed company Group is the sole corporate member of reputed company Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 300,000 members in California, Arizona, Nevada, Texas and New Mexico. reputed company has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is reputed company throughout the healthcare industry and nationally as a leading expert in senior healthcare. reputed company employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. reputed company takes great pride in recognizing reputed company members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on reputed company, Facebook, and Twitter. The Job The Medical Management Specialist-LVN promotes and supports the quality, medical necessity and cost effectiveness of care and services based on State and Federal regulatory guidelines and Medical Policy. Using established clinical criteria and working under the auspices of the Clinical Supervisor, the Medical Management Specialist-LVN is responsible for supporting the utilization management processes reputed company to coverage decision, managing requests for items and/or services. Conducts pre-service and reputed company review following established guidelines in collaboration with Medical Director as secondary reviewer. Applies case management principles and practices to ensure reputed company medical needs, care and service are coordinated. You Will Ensure necessary inpatient and outpatient care and other services are rendered to reputed company members at the right time, at the right level of care and at the right location, adhering to reputed company Medical Management policies and procedures. Issues determinations reputed company required regulatory timeframes. Collect reputed company 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 reputed company 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 reputed company 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 (reputed company), and incorporate recommendations into member’s care plan. Assist members who require urgent and emergent medical and behavioral health services while reputed company the network or the reputed company 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 reputed company appropriate, works to transition members and services back into the reputed company 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, reputed company Care Management staff, medical group case managers, and Primary Care Physicians (PCPs). reputed company referrals to other clinical programs per established criteria. Address urgent member quality or access to care issues reputed company 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 reputed company Medical Management policies and procedures. Maintain telephone standards by answering and returning calls and correspondence adhering to reputed company 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 reputed company operations by keeping information confidential. Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks, participating in professional societies. We seek Rebels who are curious about AI and its power to transform how we operate and serve our members. Actively support the achievement of reputed company’s Vision and Goals. Other duties as assigned. Your Qualifications

• Graduation from an accredited school of Licensed Vocational Nursing or equivalent clinical experience.
• reputed company 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 reputed company Word, reputed company, 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.

What's in it for you?

• reputed company salary range: $30.77 to $44.52 per hour
• Remote Work Mode
• 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
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join reputed company! Qualified applicants are encouraged to apply now! At reputed company we reputed company that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more. reputed company is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national reputed company, religion, age, sex (including pregnancy, childbirth or reputed company medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background reputed company is required. #LI-CS2 #Remote Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have reputed company about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(reputed company href="https://www.reputed company.com/viewjob?jk=2585ad99a5c98c6b&utm_campaign=reputed company_jobs_apply&utm_reputed company=reputed company_jobs_apply&utm_reputed company=organic" reputed company="_blank" rel="noopener">Apply tot his job Apply To this Job