Reporting to the Nurse Supervisor, and Bilingual Licensed Vocational Nurse (LVN) Utilization Management Nurse is responsible for facilitating pre-certification of medical services and post-service review of medical claims by accessing network partner systems. Position will communicate with vendors to obtain and process life claims for Western Growers Assurance Trust (WGAT)/Pinnacle employer groups. Collaborates with care management nurses to coordinate medically necessary care that saves the client revenue. Assists in the process of Disease/Health Management by entering participant information into the VITAL platform computer program, contacting participants by telephone, and sending out appropriate materials to educate members about their disease processes. Incumbent will help facilitate primary care and specialist provider appointments as necessary and assure patient is managed in the least costly manner without compromising quality of care and services.

Qualifications

• Complete an accredited nursing program with an Associate Degree in Nursing (AND, preferred.
• Vocational Nurse license in the State of California required with two years of experience in health insurance preferred.
• Strong clinical assessment knowledge and health education background.
• Comprehensive understanding of generally accepted medical practice, state mandated benefits and plan language.
• Strong skills in Microsoft Office products.
• Ability to learn claims and authorization systems.
• Proficient knowledge and understanding of coding books and medical terminology.
• Comprehensive understanding of health insurance claims.
• Previous experience in utilization review, medical review and case management activities preferred.
• Excellent oral and written communication skills; Spanish fluency preferred.
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
• Home router with wired Ethernet (wireless connections and hotspots are not permitted).
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
• A functioning smoke detector, fire extinguisher, and first aid kit on site.

Duties And Responsibilities

• Perform pre-certification process by obtaining, organizing, and synthesizing clinical, benefit, and network information.
• Obtain and maintain clinical records from providers and facilities.
• Assist with development of the UM program, care management program and other claims management projects.
• Collect the necessary information for vendor network to initiate processing of life claims. Submit complete information to vendor network.
• Perform claims medical necessity review.
• Maintain positive working relationship with Provider Maintenance (PM) Department and advise PM of issues with contracting, network, and rosters.
• Determine when physician advisor involvement is appropriate on a case-by-case basis. Follow-up with the results of reviews sent to physician advisors.

• Maintain appropriate turnaround times for routine, urgent, and stat authorization requests.
• Train new Intake Coordinators and assist with training for new employees in care management.
• Utilize appropriate security techniques to ensure HIPAA required protection of all confidential   protected client data.
• Provide education and coaching to members in the Health Management program.

• Handle all initial and follow up assessments related to our participants understanding and acceptance of the current and projected future needs to best manage their disease state.
• Establish and manage daily schedules with preference to the individual needs of clients and members. Maintain Outlook calendar for transparency and to allow support staff the ability to book member assessments and follow-up appointments.   
• Forward clinical issues to the appropriate nursing staff for review and input and follow up on plan of care and administrative issues as appropriate.
• Enter accurate and complete updates and ongoing tracking measures into the computer system including any updates to the participant plan of care.
• Work with Claims, Customer Service, and Provider Maintenance and Contracting staff, as necessary, to provide input on any special needs or circumstances of participants.
• Enter new Health Management cases on members as appropriate.
• Provide education materials by mail for the members, follow up that they were received, determine that they understand their use, and answer any questions the participants may have.
• Maintain records of patient related phone conversations in the appropriate system.
• Transmit correspondence or medical records by mail, e-mail, or fax maintaining appropriate confidentiality.
• Send cases approved by supervisor to outside medical review consultant and document in appropriate spreadsheet.
• Receive and review medical documents as appropriate and protect the security of medical records to ensure that confidentiality is maintained.
• Compile and record medical reports or correspondence in the appropriate reporting software.

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results.
• Maintain a valid Vocational Nurse license in the state of California.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
• Other duties as assigned.

Physical Demands/Work Environment