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Medical Management Specialist RN/LVN

Company: Scan Health Plan
Location: Long Beach
Posted on: January 16, 2022

Job Description:

About SCANAs one of the nations largest not-for-profit Medicare Advantage plans, serving more than 200,000 members in California, SCAN Health Plan has been a mission-driven organization dedicated to keeping seniors healthy and independent for over 40 years. SCAN employees are passionate about what they do, and understand that success is based on achieving the mission. Employees are afforded with the training and tools necessary to do their jobs and are rewarded for their efforts and recognized as experts in their fields. To learn more, visit scanhealthplan.com or follow us on social media: LinkedIn; Facebook; and Twitter.
The JobThe Medical Management Specialist-LVN/RN 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 related to coverage decision, managing requests for items and/or services. Conducts pre-service and concurrent review following established guidelines in collaboration with Medical Director as secondary reviewer. Applies case management principles and practices to ensure complex medical needs, care and service are coordinated.
You WillEnsure necessary inpatient and outpatient care and other services are rendered to SCAN members at the right time, at the right level of care and at the right location, adhering to all Medical Management policies and procedures. Issues determinations within required regulatory timeframes.Collect all 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 optimum 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 complex 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 (IDT), and incorporate recommendations into members care plan.Assist members who require urgent and emergent medical and behavioral health services while outside the network or the SCAN 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 when appropriate, works to transition members and services back into the SCAN 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, SCAN Care Management staff, medical group case managers, and Primary Care Physicians (PCPs).Make referrals to other clinical programs per established criteria.Address urgent member quality or access to care issues via 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 all Medical Management policies and procedures.Maintain telephone standards by answering and returning calls and correspondence adhering to all 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 members right to privacy and protect SCAN operations by keeping information confidential.Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks, participating in professional societies.Other duties as assigned.
Your Qualifications

  • Graduation from an accredited school of Licensed Vocational Nursing or equivalent clinical experience.
  • Current and active California Licensed Vocational Nurse is required. Registered Nurse license preferred.
  • 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 Microsoft Word, Excel, 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.
    Covid-19 Vaccination PolicyTo ensure a healthy and safe work environment, all SCAN employees will be required to be fully vaccinated by January 1, 2022. Generally, you are considered fully vaccinated 14 days after receiving the last dose, as recommended by the manufacturer, of a vaccine that has been authorized by the FDA for use in the United States, including vaccinations that have been approved pursuant to an Emergency Use Authorization. If fully vaccinated outside of the United States, the vaccination must be listed for emergency use by the World Health Organization (WHO). If you cannot receive the vaccine because of a disability/medical reason or sincerely-held religious belief, you may request an accommodation to this requirement by contacting COVID-19@scanhealthplan.com. Learn more about the COVID-19 vaccination here - https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html.
    What's in it for you?
    • A competitive compensation and benefits program
    • An annual employee bonus program
    • Robust Wellness Program
    • Generous paid-time-off (PTO)
    • Ten paid holidays per year, plus 1 additional floating holiday
    • Excellent 403(b) 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 our team! Qualified applicants are encouraged to apply now!
      At SCAN we believe 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.
      SCAN 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 origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.by Jobble

Keywords: Scan Health Plan, Long Beach , Medical Management Specialist RN/LVN, Healthcare , Long Beach, California

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