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LVN Utilization Review

MemorialCare Medical Foundation • Fountain Valley, California, United States • $34.79 - $50.42 / hour • 1m ago

Title: LVN Utilization Review

Location: Fountain Valley

Department: Outpatient Utilization Management

Status: Per-diem

Shift: Days

Pay Range*: $34.79/hour - $50.42/hour

At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. Memorial Care stands for excellence in Healthcare. Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.

Position Summary

Underminimalsupervision and using clinical experience, evidence-based knowledge and in collaboration with our physicians, to process clinically appropriate care management referrals.Essential Functions and Responsibilities of the Job

1.Alongwithphysicianhospitalists/PCPs / Specialists,leadsandcoordinatesactivitiesof interdisciplinarytreatmentteamrequiredtomakecomplexclinical,benefitandnetworkdecisions.

2.Analyzedatatoidentifyunder/overutilization;improveresourceconsumption;promotepotential reductionincost;andenhancequalityofcareconsistentwithMemorialCareMedicalFoundation strategicgoalsandobjectives.

3.Apply Utilization ReviewManagementprocesstoensurecontinuityofcarethroughoutthehealthcare continuumincludingreviewandauthorizationofservicesapplyingevidence-basedguidelinesand perMemorialCareMedicalFoundationpolicy.

4.Assuresreviewturnaroundtimesadhereto timelinessstandardssetbycontractingandregulatory requirementsandestablishedproductivityandqualityguidelines.

5.Decisionsanddocumentationdemonstrateprudentutilizationofresources,identifies forpotentialcostreduction;promotequalitycareandcomplywithregulatory guidelinesneededtomaintaindelegatedstatusfromcontractedhealthplans.

6. Assists with developingcorrectiveactionplans,createpoliciesanddesignworkflowsthatoperationalize improvementsidentifiedthroughdata and leadershipanalysis.

7.Documentsdecisionsthatdemonstrateindependentjudgment,criticalthinkingandapplicationof complexmanagedcareregulationsincludingbut notlimited tobenefitstructures, health plan coverage, medicalnecessity,networkcontract,financialresponsibilityandcaremanagement.

8.Implementandmaintainsystemsandprocessesthatmeetvariousregulatoryrequirements.

9.Interpretsandappliesdelegationagreements,divisionsoffinancialresponsibility,contracted providerlists,evidenceofcoverage,healthplanoperationsmanuals,and MemorialCareFoundationpolicy.

10.Independentlyresearchanddeterminetheinformationnecessarytosatisfyspecificbusinessand regulatorymedicalmanagementrequirements. Initiateandcompletethedenialprocessforall servicesdeemedtobe non-coveredbenefitsornot medicallynecessary.

11.May be called upon to participateinregulatorycomplianceauditrequirementsandactivities/committeesincludingbutnotlimited toUtilizationManagement,QualityImprovementand PerformanceImprovement.

12.Maintainanddemonstrateacompleteunderstandingofownscopeofpracticeoflicensure and educationlevel.

13.Monitorsutilizationandprovidesrecommendationsforimprovementagainstestablishedindustry standardsandperformancemeasurementmetrics.

14.Works with Managers to overseeapproval,denial andappealprocess,includingimplementationofappropriatedenialletter languagetomeetregulatorystandards.

15.ParticipatesinContractingandProviderRelationsactivitiesasnecessarytodevelopandmaintainprovidernetworks.

16.Subjecttostandardmedicalmanagementperformancemeasurementsforspecificarea/team includingbut notlimitedtoreferralturnaroundtimes,volume,deniallanguageandoverturnrates.

17.May be required to travel during shift for meetings and staff oversite.

18.May be required to work remote to meet business needs for regulatory compliance.

*Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare—that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there’s more...Check out our MemorialCare Benefits for more information about our Benefits and Rewards.

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