Overview:
Dignity Health Medical Foundation established in 1993 is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health – one of the largest health systems in the nation - with hospitals and care centers in California Arizona and Nevada. Today Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers we provide increasing support and investment in the latest technologies finest physicians and state-of-the-art medical facilities. We strive to create purposeful work settings where staff can provide great care while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled qualities that are vital to maintaining excellence in care and service.
Responsibilities:***This position is hybrid in-office/clinic and work from home.
Position Summary:
The Utilization Review (UR) LVN uses clinical judgement in providing utilization management (UM)services. The focus is to provide high quality cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary. The LVN assists in determining appropriateness quality and medical necessity of referral requests using pre-established guidelines. This position supports the Medical Group in effective management of the managed care patient. This position may be assigned cases in pre-authorization areas in skilled nursing facility review or in concurrent review.
Responsibilities may include:
- Conducts pre-authorization referral reviews following workflow as written document criteria to make determination or recommendation and process the referral in a timely manner.
- The LVN supports the quality programs within the Department through participation in projects reviews and compliance with policies and practices.
- The LVN provides appropriate support to co-workers leaders physicians referral sources and other departments during all work activities.
Minimum Qualifications:
- 3 years Utilization Management (UM) experience. 5 years LVN experience.
- Clear and current CA LVN license.
- Knowledge of health plans. Medical specialty procedures and diagnoses.
- Strong knowledge nursing requirements in a clinical setting. Knowledge of utilization management programs as related to pre-set protocols and criteria.
- Ability to work within an interdisciplinary structure and function independently in a fast paced environment while managing multiple priorities and meeting deadlines.
- Ability to apply clinical judgment to complex medical situations and make quick decisions.
- Ability to read and interpret benefit contract specifications.
- Ability to understand and follow established criteria and protocols used in managed care functions.
- Strong organizational skills.
- Effective telephone and computer data entry skills required.
- Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses.
Preferred Qualifications:
- General knowledge of UM and Managed Care preferred.
- Use of InterQual guidelines preferred.
- Experience at meeting deadlines by prioritizing work flow preferred.
- Physician group experience preferred.
- Knowledge of California health plans and differences between commercial and advantage plans preferred.
- Familiarity with business practices and protocols with ability to access data and information using automated systems preferred.
- Ability to communicate effectively with coworkers, members, their families, physicians and health care providers preferred.
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