Hybrid Remote Outpatient Utilization Review Nurse (LPN/LVN) – California
- Clinical License LPN
- State(s) CA
Under the direction and oversight of the Supervisor of Utilization Management, the Senior Outpatient Utilization Review Nurse is responsible and accountable for coordination of services for members of Vivant Health, LLC “Vivant” for outpatient services as delegated. The Senior Outpatient Utilization Review Nurse coordinates all systems/services needed for an organized, multidisciplinary, patient centered team approach, and cost-effective care for Managed Medi-Cal patients. The Senior Outpatient Utilization Review Nurse follows and manages the course of treatment for patients while coordinating care with physicians, nurses, case managers and other staff from outside Vivant and within Vivant to ensure quality care and safe outcomes. The Senior Outpatient Utilization Review Nurse also incorporates disease management protocols, ensures continuity of care through utilization of resources and refers to the health plans when applicable. Employees may have the option to work from home and we are currently seeking employees who live in the greater Sacramento Area in California.
Essential Job Functions:
Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the position.
- Responds to complex medical issues, ensures consistency in the benefit application, may lead cross functional teams, projects, initiatives, process improvement activities.
- Serves as a proctor to new hires and participates in the training and/or retraining of nurses.
- Responsible for managing a continuum of care for patients discharged to outpatient services.
- Partners with medical staff, utilizes scientific evidence for best practices, relevant data and compliance with the mission/philosophy, standards, goals and core values.
- Proactively assesses all potential case management and CCS member cases identified from either external or internal sources and actively manages all high-risk, high-volume cases throughout the continuum of the member’s health care needs or until they reach a maintenance mode.
- Demonstrates a multidisciplinary approach in identifying problems, communication and negotiating with the member’s PCP, family members, caregivers, other members of the health care team, community resources and the Health Plans.
- Researches and refers members to sources for alternative funding, community services and other services which may provide support to the patient and family.
- Tracks all CCS referrals for timely notification of decisions. Assists Medical Director with CCS appeals as applicable.
- Coordinates care for CCS members between PCP, CCS providers and other physicians and providers as needed as applicable.
- Identifies cases for possible peer reviewers to evaluate the appropriateness and necessity of care and or quality of care concerns.
- Assures referrals are complete and enrollment/eligibility benefits verified, prior to authorizing inpatient and outpatient care.
- Will be required to review Requests for Authorizations and approve and/or refer to Medical Director/Chief Medical Officer for review and denial/modification.
- Applies managed care techniques to clinical practice within established criteria.
- Authorize outpatient services requested, determine medical necessity; specialty services, carve out services etc.
- Process provider disputes, retro-requests and reconsiderations, as applicable.
- May also refer to social worker, complex case management, or other carve out services as needed.
- Completes appropriate, accurate and timely, documentation into Vivant system
- Reports quality of care issues to the Director of UM or Medical Director/Chief medical Officer.
- Provides ongoing evaluations of UM nursing activities according to the standards established by Vivant, as well as the physicians and hospitals.
- Assists in preparing UM/QI case issues, gathering requested records/responses.
- Compliant with all departmental metrics: turnaround time, quality audits and productivity standards.
- Possess knowledge of applicable regulatory standards
- All other job-related duties as it relates to the job function or as delegated by the management team.
- Regular attendance.
- Travel as required.
- Enforces Company policies and safety procedures.
- Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
- Four years professional nursing experience in an acute care setting or outpatient setting preferred or;
- Four years utilization/case management experience in the managed care industry a plus
- Medicaid Experience a plus
- Excellent communication skills, including both oral and written.
- Excellent active listening and critical thinking and analytical skills.
- Ability to solve mid-level problems with minimal supervision.
- Has the ability to be a leader for the department, shows leadership skills and initiative.
- Ability to demonstrate professionalism, confidence, and sincerity while quickly and positively engaging providers/members.
- Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
- Ability to provide and receive constructive job and/or industry related feedback.
- Ability to maintain confidentiality and appropriately share information on a need to know basis.
- Ability to exercise sound discretion and strict maintenance of confidentiality of all confidential and sensitive communications and information.
- Ability to consistently deliver excellent customer service.
- Excellent attention to detail and ability to document information accurately.
- Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
- Demonstrate commitment to the organization’s mission.
- Must have mid-level skills in Microsoft software (Word, Excel, PowerPoint, Visio) and Access is a plus.
- Typing speed of 40 wpm or more is a plus.
- Must have the ability to quickly learn and use new software tools.
- Must have mid-level skills using e-mail applications.
- Self-motivated with strong organizational, multi-tasking, planning, and follow up skills.
- Ability to work independently as well as in a team environment.
- Ability to present self in a professional manner and represent the Company image.
Education and Licensure
- High School Diploma or GED required
- Graduated from an accredited school of nursing required
- Current and Valid California License in the following disciplines is required: Licensed Vocational Nurse required; RN License approved but not required.
- Public Health Certificate a plus
The incumbent may travel up to 5% of the time in the greater Sacramento area.