About Us:
Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.
About the role:
Under the guidance and direction of the UM department RN Manager or Director, the Utilization Management Review Nurse (LVN) performs prospective and retrospective clinical review for inpatient and outpatient authorization requests in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and applicable business requirements. Following regulatory or evidence-based guidelines, assesses for medical necessity of services and/or benefit coverage which result in approved determination for services or the need to collaborate with Medical Directors for potential denial considerations.
Day to Day:
- Conduct clinical review to ensure effective and appropriate utilization of benefits and services for prospective, concurrent and retrospective/claims review organization determination authorization requests within regulatory turnaround requirements for all SCFHP lines of business.
- Process authorization reviews by applying the appropriate clinical criteria/guidelines, policies and procedures.
- Draft and process timely notification of action (NOA) letters for authorization determinations to providers and to members, in member specific language preferences as identified within member demographic information.
- Coordinate referrals to appropriate departments or programs for member identified continuity of care needs, such as Case Management, Behavioral Health, Managed Long Term Services and Supports (MLTSS), community resources, Pharmacy and Quality.
- Maintain adherence with CMS (Medicare) and DHCS (Medi-Cal) regulatory requirements.
About you:
- Active California Board of Nursing Licensed Vocational Nurse License (LVN) without restriction.
- Minimum one year of licensed related health care experience.
- One year of experience within a Managed Care Health Plan.
- Knowledge of managed care principles and practices with emphasis in Utilization Management and/or Case Management.
- Knowledge of MediCal and/or Medicare guidelines and regulations.
- Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria or standards.
Please review the full job description on our Career’s page:
https://phf.tbe.taleo.net/phf04/ats/careers/v2/viewRequisition?org=SANTCLAR2&cws=38&rid=3127
Job Type: Temporary
Pay: $35.00 – $44.00 per hour
Experience:
- Managed Health Care Plan: 1 year (Required)
- Utilization management: 1 year (Required)
- Case management: 1 year (Required)
License/Certification:
- LVN (Required)
Work Location: Hybrid remote in San Jose, CA 95119