Medical Claims Review Manager jobs in Orange, CA

Company Overview:

Sunshine Enterprise is an industry-leading Staffing and Recruitment Firm. Our clients are fortune 500 companies, high growth start-up companies, government, and private equity firms, and lead professional services firms. As a leading force in the business landscape, we take pride in bringing together great people and great organizations by fostering a work environment that values creativity, diversity, and growth. If you're ready to embark on a rewarding career journey with a company that prioritizes its employees, explore our current job opportunities below.

Job Summary:

The Medical Case Manager (LVN) will be responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities, and ancillary providers. The incumbent will be responsible for prior authorization and referral related processes, which includes online responsibilities as well as selecting off-line tasks. The incumbent will utilize medical criteria, policies, and procedures to authorize referral requests from medical professionals, clinical facilities, and ancillary providers. The incumbent will directly interact with provider callers and serve as a resource for their needs.

Position Responsibilities

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Analyzes requests with the objective of monitoring utilization of services, this includes medical appropriateness and identifying potential high cost, complex cases for out-patient case management intervention.
• Reviews and evaluates proposed services utilizing medical criteria and/or established policies and procedures.
• Determines the appropriate action for the service being requested for approval, modification or denial and refers to the Medical Director for review when necessary.
• Reviews inpatient setting requests to determine if surgery and/or medical care is appropriate.
• Identifies diagnosis and determines the need for continuing hospitalizations, monitors the inpatient length of stay as per established guidelines and professional judgment.
• Initiates contact with patient, family and treating physicians to obtain additional information or to introduce the role of case management as needed.
• Reviews short-term cases and conducts a thorough and objective assessment of the member’s status, including physical, psychosocial and environmental.
• Develops, implements and monitors a care plan through the interdisciplinary team process in conjunction with the individual member and family in internal and external settings across the continuum of care.
• Provides cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.
• Assesses members’ status and progress, if progress is static or regressive, determines reason and encourages appropriate referrals to out-patient case management or make appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
• Establishes means of communication and collaboration with other team members, physicians, community agencies and administrators.
• Prepares and maintains appropriate documentation of patient care and progress within the care plan.
• Acts as an advocate in the client’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
• Collaborates with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem-solving complex cases.
• Documents clinical information into the case notes along with the rationale for all decisions in the Guiding Care system.
• Completes other projects and duties as assigned.
  
  

Possesses the Ability To:

• Evaluate the quality of necessary medical services and be able to acquire and analyze the cost of care.
• Assist in the formulation of medical case management policies and procedures, understand and interpret policies, procedures and regulations.
• Assess resource utilization, cost management and negotiate effectively.
• Prepare clear, comprehensive written and oral reports and materials.
• Establish and maintain effective working relationships with CalOptima Health’s leadership and staff.
• Communicate clearly and concisely, both orally and in writing.
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.

Experience & Education

• High School diploma or equivalent required.
• Current, unrestricted Licensed Vocational Nurse (LVN) to practice in the State of California required.
• 3 years of Clinical Nursing Experience, with 1 year experience in a Managed Care setting required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

Preferred Qualifications

• 1 year of Concurrent Review (in-patient) experience.

Knowledge of:

• Guidelines and regulations relevant to utilization management.
• Medical Terminology.
• Medi-Cal and Medicare benefits and regulations.
• Current Procedural Terminology (CPT-4), International Classification of Diseases (ICD-10), and Healthcare Common Procedure Coding System (HCPCS) codes and continual updates to knowledge base regarding the codes.

At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization, and we are happy to offer the following benefits:

• Competitive pay & weekly paychecks
• Health, dental, vision, and life insurance
• 401(k) savings plan
• Awards and recognition programs
• Benefit eligibility is dependent on employment status

SUNSHINE ENTERPRISE USA LLC is an Equal Opportunity Employer and does not discriminate based on race or ethnicity, religion, sex, national origin, age, veteran disability or genetic information or any other reason prohibited by law in employment.