Department(s): Utilization Management, Prior Authorization (CR)
Reports to: Manager, Utilization Management
Hourly: $33.65 - $54.93
Duration: Up to 6 months
 
Job Summary
The Medical Case Manager (LVN) (Concurrent Review) will be responsible for providing case management intervention on behalf of members with short term, stable and predictable courses of illnesses. The incumbent will be responsible for answering the medical appropriateness, quality and cost effectiveness of proposed hospital/medical/surgical services in accordance with established criteria.
 
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 client 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 case management and utilization management.
Confidentiality and the legal and ethical issues pertaining to case management.
International Classification of Diseases (ICD-9/ICD-10) and Current Procedural Terminology (CPT) coding requirements.
Available community resources.
Effective charting practices and guidelines.
Available medical treatments and resources. 


The Midtown Group is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. We are a small, woman-owned business certified by the Women’s Business Enterprise National Council (WBENC). Operating from our headquarters in Washington, DC, we provide trusted staffing services nationwide. Our clients include thousands of the most prestigious Fortune 500 companies, law firms, financial organizations, tech innovators, non-profits, and lobbying firms, as well as federal, state and local government agencies.