Temp Medical Case Manager Lvn Prior Auth

Sunshine Staffing is seeking a Medical Case Manager (LVN). The Medical Case Manager (LVN) provides case management intervention on behalf of members with short-term, stable, and predictable courses of illnesses. The incumbent is 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 outpatient 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 need for continuing hospitalizations; monitors the inpatient length of stay as per established guidelines and professional judgment.
  
• Initiates contact with patients, family, and treating physicians to obtain additional information or to introduce the role of case management as needed.
  
• For short-term cases, 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 member’s 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 and solving complex cases.
  
• Documents clinical information into the case notes along with the rationale for all decisions in the Guiding Care system.
  
• 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.
  
• 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.
  
• Establish and maintain effective working relationships with CalOptima leadership and staff.
  
• Assess resource utilization, cost management, and negotiate effectively.
  
• Prepare clear, comprehensive written and oral reports and materials.
  
• Communicate clearly and concisely, both orally and in writing.
  
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) 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 of which 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 is also qualifying.
  

Preferred Qualifications:

• 1 year of Concurrent Review (In-Patient) experience preferred.
  

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 is an “Equal Opportunity Employer—Minorities, Females, Veterans and Disabled Persons”

• 401(k)
  
• Dental insurance
  
• Health insurance
  
• Paid time off
  
• Vision insurance