Job Overview
Company Information
Calibrated Healthcare is a Business Process Outsourcing (BPO) company providing healthcare administration and administrative support for medical management for its clients in the Healthcare industry. Headquartered in Ontario, California, we currently have offices in India and the Philippines providing various administrative services to our clients.
Position Description
The Utilization Review LVN is responsible for ensuring a collaborative process of assessment/problem identification, care plan development, facilitation of the care plan, care coordination, evaluation, and continuous monitoring of an assigned population of patients across care settings.
Licensure/Certification
- A current active LVN license issued by the California Board and State you reside in (Texas, Florida, Tennessee, North Carolina or Georgia)
Experience
- Experience interpreting evidenced based guidelines (Medicare Guidelines, Medi-cal, Milliman criteria sets, etc.), health plan rules, and policies/procedures
- 2-3 years managed care experience preferred
- 2-3 years case management experience preferred
Job Skills
- Core Competencies: Ethics and Values, Customer Focus, Action-Oriented, Learning on the Fly, Manage/Measure Work, Drive for Results, Priority Setting, Timely Decision-Making, Organizing, Functional and Technical Skills
- Demonstrated ability to work together across professions and individuals to improve health outcomes.
- Computer Proficiency (MS Word, MS Excel, MS Outlook, Video Conferencing)
- Knowledge of NCQA, DMHC, and state requirements for case management, Clinical guidelines (MCG).
Essential Job Functions
- Responsible for ensuring the accuracy of member eligibility verification, member benefit verification, and network utilization to ensure accurate authorization adjudication.
- Able to accurately navigate the client-based UM platform and accurately enter authorization request data
- Effectively prepares authorization request for next level of review; to include, appropriate request of additional information, pre-certification verification, clinical recommendation, and accurate network utilization
- Consistently meets or exceeds departmental production standards and quality standards.
- Compliant with turnaround timeframes for authorization adjudication and provider notification.
- Ensures appropriate escalation of concerns; to include, but not limited to, Contracting issues (LOA, MOU) or Quality/Access concerns.
- Appropriately identifies criteria used for clinical decision making.
- Accurately and timely generation of denial or modification communication based on next level review outcomes, when applicable
- Able to perform focused provider reviews based on identified over or under utilization of services when directed.
- Able to provide data in an actionable manner upon completion of focused provider reviews.
- Adheres to Desktop Procedures and UM Policies and Procedures
- Adheres to the client defined adjudication rules for UM Nurse Reviewer level of review
· All other duties as assigned
Pay: $24.00 - $35.00 per hour
Benefits:
Application Question(s):
- What clinical criteria have you used?
License/Certification:
- California license (Required)
Work Location: Remote
