Job Description:

Temp. In-Patient Utilization Review Nurse (Medical Case Manager)

Sunshine Staffing is seeking Medical Case Manager (LVN). The Medical Case Manager (LVN) provides case management intervention on behalf of members with short term, stable, and predictable courses of illnesses. The incumbent is responsible for answering the medical appropriateness, quality, and cost effectiveness of proposed hospital/medical/surgical services in accordance with established criteria.

Position Responsibilities:

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Analyzes requests with the objective of monitoring utilization of services, this includes medical appropriateness and identifying potential high cost, complex cases for outpatient case management intervention.
• Reviews and evaluates proposed services utilizing medical criteria and/or established policies and procedures.
• Determines the appropriate action for the service being requested for approval, modification, or denial, and refers to the Medical Director for review when necessary.
• Reviews inpatient setting requests to determine if surgery and/or medical care is appropriate.
• Identifies diagnosis and determines need for continuing hospitalizations; monitors the inpatient length of stay as per established guidelines and professional judgment.
• Initiates contact with patient, family, and treating physicians to obtain additional information or to introduce the role of case management as needed.
• For short-term cases, conducts a thorough and objective assessment of the member’s status including physical, psychosocial, and environmental.
• Develops, implements, and monitors a care plan through the interdisciplinary team process in conjunction with the individual member and family in internal and external settings across the continuum of care.
• Provides cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.
• Assesses member’s status and progress; if progress is static or regressive determines reason and encourages appropriate referrals to out-patient case management or make appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
• Establishes means of communication and collaboration with other team members, physicians, community agencies, and administrators.
• Prepares and maintains appropriate documentation of patient care and progress within the care plan.
• Acts as an advocate in the client’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
• Collaborates with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem and solving complex cases.
• Documents clinical information into the case notes along with the rationale for all decisions in the Guiding Care system.
• Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.
• Completes other projects and duties as assigned.

Possesses the Ability To:

• Evaluate the quality of necessary medical services and be able to acquire and analyze the cost of care.
• Assist in the formulation of medical case management policies and procedures; understand and interpret policies, procedures, and regulations.
• Establish and maintain effective working relationships with CalOptima leadership and staff.
• Assess resource utilization, cost management, and negotiate effectively.
• Prepare clear, comprehensive written and oral reports and materials.
• Communicate clearly and concisely, both orally and in writing.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Experience & Education:

• High School diploma or equivalent required.
• Current, unrestricted Licensed Vocational Nurse (LVN) to practice in the State of California required.
• 3 years of Clinical Nursing Experience of which 1 year experience in a Managed Care setting required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Preferred Qualifications:

• 1 year of Concurrent Review (In-Patient) experience preferred.

At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:

•        Competitive pay & weekly paychecks

•        Health, dental, vision, and life insurance

•        401(k) savings plan

•        Awards and recognition programs

•        Benefit eligibility is dependent on employment status.

Sunshine Enterprise USA is an “Equal Opportunity Employer—Minorities, Females, Veterans and Disabled Persons”