Care Manager – LVN

Role Overview

• Coordinate care for members in collaboration with the Integrated Care Team, ensuring members are directed to the optimal facility for their needs and have all necessary services, supplies, and information.
• Authorizes services based on well-developed knowledge and skills in areas of utilization management, medical necessity, and patient status determination.
• Conduct pre-service and concurrent review following established guidelines.
• Applies care management principles and practices to ensure medical needs, care, and service are coordinated.
• Serve as point of person to speak with patients, family members, and providers to address concerns pertaining to care, transfers and authorizations.
• Review patient’s clinical information and authorize requested medical services in a timely manner.
• Ensure necessary inpatient and outpatient care or other services are rendered to SCAN members at the right time, the right level of care and at the right location while adhering to all policies and procedures.
• Issue determinations within required regulatory timeframes.
• Apply evidenced-based criteria and guidelines as well as clinical judgment and expertise to assess treatment plans.
• Manage member medical cases by applying the essential activities of care management and utilization management including assessment, planning, implementation, coordination, advocating, monitoring, and evaluation.
• Refer cases that do not meet established criteria to the Integrated Care physicians for secondary review.
• Review all acute/skilled nursing appeals and create detail explanation of non-coverage and reinstatement letters.
• Prepare, participate and facilitate high risk huddles and skilled nursing rounds.
• Maintain a list of high risk patients and conduct regular outreach calls to check on their health status.
• Coordinate timely delivery of last day cover letters to skilled nursing facilities.
• Coordinate discharge needs from inpatient acute settings and skilled nursing facilities as appropriate for each member.
• Review tasks assigned by Integrated Care Nurse Practitioners and coordinate member care accordingly, including services such as: home health; DME ordering, wound care, Foley catheter, Enteral, colostomy supplies, infusion orders and outpatient services.
• Coordinate direct admissions to skilled nursing facilities and direct ER transfers from senior living communities.
• Develop effective working relationships and provide clinical guidance to Care Coordinators on clinical matters.
• Demonstrate excellent organizational, decision-making and multi-tasking skills as demonstrated by problem solving and successful outcomes.
• Promote the mission, vision, and values of SCAN Health Plan and serve as an ambassador when interfacing with external stakeholders.
• Actively support the achievement of SCAN’s Vision and Goals.

Requirements

• CA Licensed Vocational Nurse (LVN) required.
• Clinical nursing experience (2-4 years)
• Experience in care or utilization management (2+ years)
• 5+ years of experience in healthcare, medical management, change management, and/or leadership.
• Ability to communicate effectively verbally and in writing
• Highly organized with attention to detail
• Resourceful problem solver
• Strong interpersonal skills, hospitality, and change agent mindset
• Adaptable and open to change
• Knowledge and/or familiarity with the principles of project and program management.
• Demonstrated ability to develop and implement new, replacement systems, and gain buy-in from appropriate audience.
• Able to lead and influence those without direct reporting relationships to achieve desired outcomes.
• Ability to communicate with clarity, the vision, value, and tasks to formal and informal audiences.
• Able to develop relationships quickly and leverage working relationships to drive performance outcomes.
• Strong organizational skills; Ability to multitask and to appropriately maintain confidentiality.

Benefits

• Remote Work Mode
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
• Excellent 401(k) Retirement Saving Plan with employer match and contribution
• Robust employee recognition program
• Tuition reimbursement