Utilization Management Nurse Specialist LVN II

Job Summary

The Utilization Management Nurse Specialist LVN II for the Utilization Review Clinical Department is primarily responsible for the overall coordination for L.A. Care Health Plan Direct Lines of Business under the direction of a Registered Nurse. This position works collaboratively with the health care team to coordinate care and placement for the Skilled Facility admissions. Member’s needs may include physical health, discharge planning, behavioral health, social services and Skilled Care Facility services and supports.

In collaboration with the Supervising RN and other treatment professionals, this position: performs telephonic assessment of identified L.A. Care members who are pending discharge from the acute care hospital to a Skilled Facility, transfer from one Acute to another, and transition from a Skilled Nursing facility out to the community. The goal is to provide timely transition of care from the Acute setting in a safe and coordinated approach within the clinical team.

This position will work in supporting the Coordination of Care services for transitioning members from all lines of business.

Duties

Performs utilization review and case management functions under the direct supervision of a Registered Nurse for the L.A. Care Members utilizing considerable clinical judgment, independent analysis, critical thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans to complete review and determinations within required timeframe. Acts as the primary liaison between L.A. Care,  skilled nursing facilities (SNF's) and the Long Term Care department. Medical Director; liaison with acute care facility and SNF where members are being transitioned to alternative facilities or home.  Assist with discharge planning process and coordination between acute, SNF and/or lower level of care to ensure a smooth transition throughout the continuum of care. Develop and maintain effective working relationships with all levels of staff, other programs, and agencies; communicate effectively at all organizational levels and in situations requiring instructing, negotiating, consulting, and advising; implement/conduct specific interventions, including referring members to outside resources and/or community agencies, that will result in meeting the goals established in the care plan. For short term cases, gather all information pertinent to the member’s physical, psychosocial, behavioral, and social status; develop for a complete clinical referral to the transitioning SNF facilities. Collaborates and communicates with the Member, family, significant other(s) and other health care providers to support and accomplish goals identified on the ICP in all care settings and maintains appropriate documentation. Consult with the RN to determine the appropriate action with regard to the service being requested for approval, modification or denial, and refer to the Medical Director for review when necessary.

Under the direct supervision of a RN, performs regular review of cases and events to identify patterns/ trends and to ensure the L.A. Care’s compliance with Centers for Medicare and Medicaid Services(CMS), Department of Health Care Services (DHCS) and National Committee for Quality Assurance (NCQA) standards. Meets L.A. Care and regulatory standards for accuracy, proficiency and documentation in order to communicate decisions and plan of care in an appropriate and timely manner. Calculates cost savings that may result from redirecting member to a more appropriate care setting.

Ensure utilization of Skilled Nursing Facility supportive or rehabilitative services within contracted network. Communicates with ancillary departments, such as Provider Network Operations (PNO) and Case Management, as necessary, to meet individual needs of members and providers. Understands and maintain confidentiality and the legal and ethical issues in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.

Participates in the department’s continuous quality improvement activities. Communicates to UM Manager and supervising RN, barriers to completing assignments or daily work in an efficient and effective manner.

Perform other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:
At least 3-5 years of clinical experience in Utilization Management/Case Management
HMO managed care experience with prior experience in ambulatory case management, utilization management, disease management or any combination of education/experience.

Good working knowledge of regulatory requirements/standards of Title 22 and State Regulations.

Experience working with the Medi-Cal and Medicare populations.

Preferred: 
Experience in rehabilitation therapies(inpatient or outpatient); knowledge of available community resources; experience in working and referral to community based organizations.

Previous experience in a health plan and/or Independent Practice or Physician Association (IPA)/Participating Physical Group (PPG) setting developing and performing UM case management/case management a plus.

Skills

Required:
Strong clinical skills with a knowledge of care needs for elderly, disabled, and or frail populations; effective charting practices and guidelines.

Effectively utilize computer and appropriate software and interacts as needed with L.A. Care Information System.

Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. 

Excellent time management and priority-setting skills.

Maintains strict member confidentiality and complies with all HIPAA requirements.

Strong verbal and written communication skills.

Preferred:
Principles and practices of health care, health care systems and medical administration.

Knowledge of MDS 3.0 Process.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Required:
L.V.N.

Additional Information