Case Manager – LVN or RN, Pediatric, CCS

Role Overview

• Comply with Case Management Department’s policies and procedures
• 95
• 100% compliance with Utilization Management health plan delegation standards for Case Management
• Utilize Milliman Care Guidelines criteria for appropriateness of transition to care by level of skilled needs and acute rehab for post discharge plan
• Collaborating with Hospitalists, case managers, and discharge planners to establish discharge plans at time of admission
• Responsible for coordinating the required initial and concurrent reviews based on the review of medical records received and daily accurate reporting of all inpatient admissions to Medical Director and Manager and/ or Supervisor of Case Management Department
• Review of medical records and/or other documentation to determine medical necessity, appropriateness and level of care utilizing Milliman Care and other appropriate Guidelines
• Assess, plan, implement, coordinate, monitor, and evaluate all options and services with the goal of reducing hospital readmission
• Attends/coordinates Case Management meetings on and off-site as necessary
• Conduct Hospital On-Site visits with members to ensure transition of care from hospital to lower level of care
• Interacts with the providers or members as appropriate to communicate determination outcomes in compliance with state, federal and accreditation requirements
• Attend to provider and interdepartmental calls in accordance with exceptional customer service
• Maintain good relationships with health plans, hospitals and medical directors. Resolve problems that arise with any IPA medical directors
• Report to Manager and/or Supervisor of Case Management on activities and/or problems occurring throughout the day
• Other duties as assigned

Requirements

• Active Registered Nurse (RN) license in California OR active Licensed Vocational Nurse (LVN) license in California
• Ability to commute to our Monterey Park, CA office
• Experience using Microsoft applications such as Word, Excel and Outlook
• Two (2) years of clinical experience as an RN/LVN
• Excellent analytical critical reasoning
• Proven ability to prioritize multiple responsibilities simultaneously in a fast-paced, changing environment while meeting deadlines
• Ability to educate and train staff members and other departments as needed
• Experience using EZCAP Strong communication and customer service skills

Benefits

• Our organization follows a hybrid work structure where the expectation is to work both onsite and at home on a weekly basis. The home office is located at 1600 Corporate Center Dr, Monterey Park, CA 91754.
• The first 30 days will be fully onsite at our home office for training purposes.
• Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer.