Location: La Palma, CA
Description: Judge is currently sourcing for an LPN /LVN licensed in California for Utilization Mgmt. to coordinate in network and out of network events.
- Directly performs concurrent review.
- Accurately identifies and documents level of care.
- Coordinates, facilitates and documents comprehensive discharge planning.
- Coordinates in-network services for OON discharges.
- Ensures the appropriate utilization of capitated and contracted specialists, providers, facilities, and vendors according to region and risk.
- Attends inpatient review rounds and presents cases to medical director(s), health plans and management staff
- Facilitates OON transfers to In-Network facilities.
- Works collaboratively with internal and hospital contract staff.
- Initiates letter of agreement for OON services in a timely manner.
- Provides input for potential contracts.
- Identifies and communicates high dollar / high risk cases
- Oversees the utilization of contracted facilities and reports OON utilization.
- Develops and maintains relationships with both network and Out of Network hospital UM and ER staff.
- Works directly with site Hospitalists to develop and implements inpatient processes including, but not limited to:
- Identification of patients and referral to specialty clinics such as Comprehensive Care (high-risk) Clinic, Anti-coagulation and/or Diabetic Clinic.
- Facilitates and ensures timely communication between PCP and Hospitalists.
- Provides direct Case Management activities if necessary.
- Identifies readmit for CM coordination.
- Identifies Healthy Families and Medi-Cal members for CCS referral and facilitates those referrals
- Identifies and coordinates high dollar/high risk patients to case management.
- Participates in UMC/QIC, PCP, Provider Office Meetings, health plan JOMs, and hospital JOCs as assigned.
- Participates in inpatient UM/QM projects and completes in a thorough and timely manner.
- Other duties as assigned which may include weeknight, weekend, and holiday on-call.
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