Job Title: Healthcare Specialist Job Description As a part of the Utilization Management team, the LVN Case Manager is a member of the Care Coordination team. The LVN Case Manager handles a queue of cases based on patients' last names. All new referrals are added to this queue after authorization by the clinical team. The Case Manager must be familiar with CMS criteria as each plan has different criteria. Case volume varies daily from 30-50 cases in the queue, with a minimum expectation of processing 25 cases per day. They service patients in the Inland Empire, handling outpatient referrals and ensuring all post-discharge care is coordinated appropriately to meet patients' needs. Responsibilities + Plans for and ensures that all post-discharge care is coordinated appropriately according to the needs of the patient and ensures continuity of care. + Conducts prior authorization reviews on all services that require nurse review. + Travels to various hospitals within established areas to conduct patient visits. + Conducts inpatient and skilled nursing facility level-of-care reviews on a concurrent basis. + Plans for and coordinates all discharges from inpatient and skilled nursing facilities. + Makes outbound calls to patients according to case management queue assignment and case management policies and procedures. + Tracks barriers to appropriate inpatient and SNF utilization according to policy and procedure. + Attends Utilization Management and/or Quality Management meetings as needed. + Appropriately changes patient's case management status to complex case management or routine case management based on assessment of patient's medical status changes and progression of goals utilizing complex/routine case management criteria. Essential Skills + Utilization review + Prior authorization + Care management + Medicare + Referral coordination + Utilization management + Managed care Additional Skills & Qualifications + Must know CMS criteria. + Must have experience working with Provider Offices. + Must have Utilization management experience. + Must have knowledge of both MediCal and Medicare. + Experience with IDX (system) is a plus. + High School Diploma/GED + LVN: Must have a CA License + Bachelors of Science in Nursing or other clinical advanced degree preferred. + Managed care experience preferred. + Two years of experience working with a medical group or IPA preferred. + Knowledge of nursing processes, case management, and continuity of care. + Ability to apply criteria to identify the appropriate level of care on all admissions and clearly document any research conducted and rationale of decisions made. + Ability to identify care needs across the age continuum and according to principles of growth and development over the lifespan. + Ability to apply appropriate business rules, medical guidelines, and/or health plan benefits to authorization decision making. + Knowledge of network and benefit limitations and ability to collaborate with stakeholders to find alternatives that meet patient needs and achieve positive outcomes. + Knowledge of disease management strategies. Work Environment Monday-Friday 8am-5pm with a 1-hour lunch break. Overtime is possible if necessary and must be approved by the director, primarily if the queue is high. The work environment includes a small team of 2 LVN Case Managers, working in an office setting. For immediate consideration, email your updated resume to ryreyes@ actalentservices.com along with a couple of reasons why you're a strong fit for the role. Pay and Benefits The pay range for this position is $25.00 - $36.00 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 will be accepting applications until Feb 1, 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. Diversity, Equity & Inclusion At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through: + Hiring diverse talent + Maintaining an inclusive environment through persistent self-reflection + Building a culture of care, engagement, and recognition with clear outcomes + Ensuring growth opportunities for our people 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 process due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.