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Job Title: Healthcare SpecialistJob Description

Join our Utilization Management team as an LVN Case Manager, where you will be an integral part of the Care Coordination team. You will manage a queue of cases based on patients' last names, with all new referrals added after clinical authorization. Case volume varies daily, ranging from 30 to 50 cases, and you are expected to process a minimum of 25 cases per day while maintaining quality and accuracy. You will service patients in the Inland Empire, focusing on outpatient referrals.

Responsibilities

+ Plan and ensure all post-discharge care is coordinated according to patient needs, ensuring continuity of care.

+ Conduct prior authorization reviews on all services requiring nurse review.

+ Travel to various hospitals within designated areas to conduct patient visits.

+ Conduct inpatient and skilled nursing facility level-of-care reviews on a concurrent basis.

+ Coordinate all discharges from inpatient and skilled nursing facilities.

+ Make outbound calls to patients according to case management queue assignments and policies.

+ Track barriers to appropriate inpatient and SNF utilization according to policy.

+ Attend Utilization Management and/or Quality Management meetings as needed.

+ Change patient's case management status based on assessment and progression of goals, utilizing complex/routine criteria.

Essential Skills

+ Proficiency in utilization review and prior authorization.

+ Experience in care management and Medicare.

+ Knowledge of referral coordination and utilization management.

+ Familiarity with Managed Care, interqual, NCQA, and NCQA standards.

Additional Skills & Qualifications

+ Must know CMS criteria.

+ Experience working with Provider Offices is essential.

+ Utilization management experience required.

+ Knowledge of both MediCal and MediCare is necessary.

+ Experience with IDX system is a plus.

+ High School Diploma or GED required; LVN with CA license mandatory.

+ Bachelor of Science in Nursing or another clinical advanced degree preferred.

+ Managed care experience preferred.

+ Two years of experience working with a medical group or IPA preferred.

+ Understanding of nursing processes, case management, and continuity of care.

+ Ability to apply criteria to identify appropriate level of care on all admissions.

+ Ability to document research conducted and rationale of decisions made.

+ Knowledge of care needs across the age continuum and growth principles.

+ Ability to apply business rules, medical guidelines, and health plan benefits to authorization decisions.

+ Familiarity with disease management strategies.

Work Environment

Work Monday to Friday, 8am to 5pm, with a one-hour lunch break. Occasional overtime may be necessary, subject to director approval and queue demands. Opportunity to start early if needed. Join a small team within the LVN CM department in an office setting.

Pay and Benefits

The pay range for this position is $21.50 - $23.00/hr.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:

• Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on Jun 7, 2025.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email [email protected] (%[email protected]) for other accommodation options.