Location: Orange, CA
Description: Our client is currently seeking a Medical Case Manager (LVN) Pre-Auth Nurse
This job will have the following responsibilities:Reviews requests for medical appropriateness. •Verifies and processes specialty referrals, diagnostic testing, outpatient procedures, home health care services and durable medical equipment and supplies via telephone or fax by using established clinical protocols to determine medical necessity. •Screen requests for the Medical Director review, gathers pertinent medical information prior to submission to the Medical Director; follows up with the requester by communicating the Medical Director's decision; documents follow-up in the utilization management system. •Completes required documentation for data entry into the utilization management system at the time of the telephone call of fax to include any authorization updates. •Reviews ICD-10, CPT-4 and HCPCS codes for accuracy and existence of coverage specific to the line of business. •Contacts the Health Networks and/or CalOptima Customer Service regarding health network enrollments. •Identifies and reports any complaints to immediate supervisor utilizing the call tracking system, or through verbal communication if the issue is of urgent nature. •Refers cases of possible over/under utilization to the Medical Director for proper reporting. •Meets productivity and quality of work standards on an ongoing basis. •Assists Manager with identifying areas of staff training needs and maintains current data resources. •Other projects and duties as assigned.
please email me your resume for consideration asap to trutkoske@judge.com
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