Utilization Review LVN

***This position is work from home within driving distance of Woodland, CA, with occasional onsite meetings in Woodland.

Position Summary:

The Utilization Review LVN uses clinical judgement in providing utilization management 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 Woodland Clinic 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.

Responsibilties may include:
- Determines correct type of referral and utilizes correct criteria in performing review and documents appropriate sections.
- Preps case thoroughly, concisely and clearly for physician review. Researches EMR, criteria, medical policy and past history of member to detail case cleanly for MD.
- Communicates findings to physician and member in accordance with all regulatory and WCMG guidelines and documents.
- Performs Inter-Rater Reliability audits as directed by the UM Supervisor or Manager.
- Performs audits of medical records as requested or appropriate.

Minimum Qualifications:

- 3 years UM experience.
- 5 years LVN experience.
- Clear and current CA LVN license.
- Strong knowledge nursing requirements in a clinical setting.
- Knowledge of utilization management programs as related to pre-set protocols and criteria.
- Knowledge of health plans, medical specialty procedures and diagnoses.
- 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.
- Strong organization skills.
- Effective telephone and computer data entry skills required.
- Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses.
- Ability to communicate effectively with coworkers, members, their families, physicians and health care providers.

Preferred Qualifications:

- General knowledge of UM and Managed Care.
- Use of InterQual guidelines.
- Experience at meeting deadlines by prioritizing work flow.
- Physician group experience preferred.
- Knowledge of California health plans and differences between commercial and advantage plans.
- Familiarity with business practices and protocols with ability to access data and information using automated systems.

***This position is represented by SEIU-UHW

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.

One Community. One Mission. One California