Utilization Management Nurse - Licensed Vocational Nurse - LVN Job at Maren Medi

LaSalle Medical Associates is seeking a passionate and highly qualified Utilization Management Nurse with experience in the California Children's Services (CCS) program. We are committed to the success of our professionals and the families we serve through the CCS program.

To attract the best talent, we are offering a $10,000 signing bonus, paid out in three installments: one-third at the time of signing, one-third after 30 days of employment, and the final third after 90 days.

Key Responsibilities

As the Special Programs CCS Manager, your primary responsibility is to review outpatient and inpatient authorizations for members under 21 years of age to determine their eligibility for the CCS program. This role requires you to integrate your clinical knowledge with medical guidelines to assess and evaluate a member’s participation in the program.

Your duties will include:

• Interpreting Service Authorization Requests (SARs) and Notices of Action (NOAs).

• Critically examining patient medical records to ensure they meet CCS criteria.

• Assessing the severity of illnesses, intensity of services, and coordinating care.

• Managing all activities related to monitoring, interpreting, and appealing CCS approvals and denials.

• Working with a multidisciplinary team to improve documentation and identify potential appeals.

• Preparing and conducting detailed training with the provider network.

• Participating in meetings and provider training sessions, which may require travel across California.

• Completing monthly CCS health plan logs and other assigned duties.

• Creating, managing, and updating Excel spreadsheets to track the authorization process.

• Conducting complex research and analysis to improve program processes and achieve goals.

Qualifications & Requirements

• Valid California Licensed Vocational Nurse (LVN) license is required.

• Minimum of 1 year of Utilization Management experience is required.

• Minimum of 1 year of California Children's Services (CCS) experience is preferred.

• High School Diploma or equivalent is required.

• Bachelor’s degree in Health Care Administration or a related field is preferred.

Work Environment

• Majority of work will be conducted in office on site.

• Travel required to provider offices across the Central Valley, off-site meetings, and other travel as assigned.

• Phone/video, zoom contact with management, providers, health plans and vendors.