Medical Management Specialist, LVN
$64,002–$92,602 year
Remote · California, United States
Job Summary
Medical Management Specialist-LVN role facilitating and supporting quality, medical necessity, and cost-effective care within regulatory guidelines. Responsibilities include conducting pre-service and concurrent review, applying case management principles to coordinate complex medical needs, escalating to Medical Director as needed, ensuring appropriate inpatient/outpatient services, authorizing stabilize-and-transition care, facilitating safe discharges, making referrals to clinical programs, addressing urgent member quality or access issues via QOC, maintaining documentation, and building strong relationships with providers and external partners. Requires CA LVN license and knowledge of state/federal healthcare mandates; remote work in CA with a schedule Tuesday-Saturday 8am-5pm PT.
Required Qualifications
- Graduation from an accredited school of Licensed Vocational Nursing or equivalent clinical experience
- Current and active California Licensed Vocational Nurse is required
- 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
- Strong analytic and problem-solving skills
- Strong verbal and written communication skills
- 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
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