Medical Management Specialist, LVN
Core
Supports utilization management processes, coverage decisions, and case management for older adults in a Medicare Advantage and integrated care setting.
Role type
Licensed Vocational Nurse (LVN) Utilization Management Specialist
Builds
Coverage determinations, care coordination plans, and discharge transitions for SCAN members
Domain
Healthcare / Managed Care / Senior Care
Required skills
Utilization management, case management, medical necessity review, regulatory compliance (Federal/State), care coordination, discharge planning, provider network management, data entry, ICD-9/HCPCS/CPT coding
Preferred skills
Certified Professional of Utilization Management (CPUM/CPUR), knowledge of California managed care industry, Medicare/MediCal expertise
Technologies
Microsoft Word, Excel, Outlook, PowerPoint
Responsibilities
Conduct pre-service and concurrent reviews for coverage decisions; manage complex medical cases through assessment, planning, and evaluation; facilitate safe discharges and coordinate care transitions; address urgent access-to-care issues via the Quality of Care process; maintain documentation and adhere to medical policies; collaborate with interdisciplinary teams and providers.
Seniority
Mid-level, hands-on IC
