Role Description
To provide comprehensive utilization management and coordination of care for SRS Members. Ensure timely and appropriate processing of managed care referrals to meet specific healthcare criteria in a cost-effective manner utilizing available resources.
Qualifications
• California Licensed Vocational Nurse (LVN) - CA Board of Vocational Nursing & Psychiatric Technicians - REQUIRED
• 3 Years experience as an LVN in a hospital or clinical setting (Preferred)
• 2 Years utilization/Case Management experience, preferably in a Managed Care setting (Preferred)
• Experience as a case manager or discharge planner interacting with managed care payers (Preferred)
• California Licensed Vocational Nurse (LVN) - License must be unrestricted (Other Qualification Requirements)
Requirements
• Ensure consistent application of the utilization review process for effective utilization of resources.
• Identify when services are not medically necessary and/or not covered benefits and refer to Utilization Review Committee.
• Gather relevant, comprehensive information and data according to specifications.
• Complete comprehensive medical record review to gather information.
• Communicate effectively with providers and healthcare personnel to obtain data required for decision making.
• Demonstrate knowledge of Health Plan contracts and Health Plan benefits.
• Coordinate services and supplies through SRS (or health plan) contracted vendors.
• Collaborate with referring physicians, providers, or vendors.
• Advocate for both client and payer.
• Identify cost-effective, appropriate alternatives.
• Ensure high volume of referrals are processed accurately in a timely manner.
• Maintain knowledge and understanding of applicable accreditation and regulatory statutes.
• Identify opportunities for intervention which may include identification of patterns/trends.
• Communicate opportunities to Leadership.
• Engage problem-solving skills to reconcile differing points of view.
• Promote effective communication among healthcare team members, the payer, and other relevant parties.
Benefits
• Hourly Pay Range (Minimum - Midpoint - Maximum): $34.170 - $44.090 - $49.370
• The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.
• The actual pay rate and pay grade will depend on various factors, including experience, skills, education, and marketplace factors.
Company Description
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, or status as a qualified individual with a disability or any other protected class.
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