Nurse Manager - Long-Term Care jobs in Orange, CA

Company Overview: Sunshine Enterprise is an industry-leading Staffing and Recruitment Firm. Our clients are fortune 500 companies, high growth start-up companies, government, and private equity firms, and lead professional services firms. As a leading force in the business landscape, we take pride in bringing together great people and great organizations by fostering a work environment that values creativity, diversity, and growth. If you're ready to embark on a rewarding career journey with a company that prioritizes its employees, explore our current job opportunities below.

Job Summary: The Medical Case Manager (LVN) (CalAIM and Long Term Care (LTC)) will be responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities and ancillary providers. The incumbent will be responsible for CalAIM and LTC authorization and referral related processes that include online responsibilities as well as selected off-line tasks. The incumbent will utilize Plan Health and CalAIM medical criteria, policies and procedures to authorize referral requests from health networks, medical professionals, clinical facilities and ancillary providers. The incumbent will directly interact with provider callers and serve as a resource for their needs.

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.
• Reviews requests for medical appropriateness for CalAIM and LTC services utilizing medical criteria and established policies and procedures.
• Verifies and processes CalAIM and LTC referrals via Health Connect, telephone or fax by using established clinical protocols to determine medical necessity.
• Completes required documentation for data entry into Health Connect and Guiding Care at the time of the telephone call, fax, or medical information system to include any authorization updates.
• Coordinates member care with health networks Health team members and CalAIM providers.
• Identifies and reports any complaints to the immediate supervisor utilizing the call tracking system or through verbal communication if the issue is of urgent nature.
• Meets productivity and quality of work standards on an ongoing basis.
• Assists the Long-Term Care manager with identifying areas of staff training needs and maintains current data resources.
• Completes other projects and duties as assigned.

Possesses the Ability To:

• Use problem-solving, organizational and time management skills, along with the ability to work in a fast-paced environment.
• Prepare clear, comprehensive written and oral reports and materials.
• Establish and maintain effective working relationships with leadership and staff.
• Communicate clearly and concisely, both orally and in writing.
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) 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) license to practice in the State of California required.
• 3 years of nursing experience, with 1 year as a Clinical Nurse Reviewer, 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

• § Managed care experience.
• § Concurrent review experience.
• § Bilingual in English and in one of defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

Knowledge of:

• § Guidelines and regulations relevant to utilization management.
• § Medical Terminology.
• § Medi-Cal and Medicare benefits and regulations.
• § Current Procedural Terminology (CPT-4), International Classification of Diseases (ICD-10), and Healthcare Common Procedure Coding System (HCPCS) codes and continual updates to knowledge base regarding the codes.
• § Available community resources.
• § Effective charting practices and guidelines.
• § Available medical treatments and resources.
• § Principles and practices of health care, health care systems and medical administration.

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 LLC is an Equal Opportunity Employer and does not discriminate on the basis of race or ethnicity, religion, sex, national origin, age, veteran disability or genetic information or any other reason prohibited by law in employment.