LVN Case Manager - Utilization Mgmt

$40,498 - $79,206/Yr

Optum - Arcadia, CA

Full-time - Mid Level

Arcadia, CA

Insurance Carriers and Related Activities

About the position

The LVN Case Manager - Utilization Management role at Optum involves overseeing medical necessity reviews for various healthcare services. This position is integral to ensuring that patients receive appropriate care while adhering to established guidelines and regulations. The role requires collaboration with a team of healthcare professionals and demands a high level of accountability and documentation accuracy.

Responsibilities

• Conduct medical necessity reviews for inpatient, outpatient, home health, injectable medications, and DME/Orthotics/Prosthetics referrals.
• Utilize the Health Plan's Evidence of Coverage and Benefits, MCG guidelines, and CMS website for accurate assessments.
• Complete all required documentation timely and accurately, applying review criteria based on the line of business.
• Collaborate daily with the UM Referral Management team, including Care Coordinators and Medical Directors.
• Communicate authorization or denial of services to relevant parties, including patients and healthcare providers.
• Demonstrate accountability for assigned referrals and meet productivity and quality audit targets.
• Ensure compliance with HIPAA standards regarding patient health information.

Requirements

• Graduation from an accredited Licensed Vocational Nurse program.
• Active, unrestricted LVN license in California.
• 2+ years of experience in referrals and utilization management.

Nice-to-haves

• 3+ years of experience as an LVN/LPN.
• Experience in an HMO or Managed Care setting.
• General knowledge of medical terminology and ICD-10 and CPT/HCPCS coding.

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution