Job Description

Job Description

Job Description

La Salle Medical Associates IPA (Maren) is searching for a highly qualified, engaging, team oriented and passionate professional who has experience with California's Children's Service (CCS) program, we hope to hear from you. We have a highly motivated team of professionals who are committed to the CCS program and to your success If you have a current CA LVN license, we invite you to consider joining our talented team.

The primary responsibility of the CCS Manager, Nurse Reviewer is to perform a review of both outpatient and inpatient authorizations for all members under the age of 21 to determine if the member meets criteria for the California Children’s Services program (CCS). In order to perform duties, the candidate must have an understanding of the CCS program, including the diagnoses that qualify, the application process, be able to interpret Service Authorization Request (SAR) and Notice of Action (NOA), understand the severity of and array of illnesses, intensity of service, and care coordination. The candidate must integrate clinical knowledge with medical guideline knowledge to review and evaluate member’s acceptance and participation in the CCS program. As a Nurse Reviewer, the candidate will be responsible to prepare and conduct detailed training for the provider network and new hires regarding the CCS program. May be required to drive and meet with patients and providers. This position will have no direct reports.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Works with the multidisciplinary team to assess and improve documentation, identify potential appeals with CCS and be able to process applications using health plan and state guidelines

Manages all activities related to the monitoring, interpreting, and appealing of CCS approvals and denials

Critically examine patient medical records, paying close attention to the appropriateness of submitting applications to the state of CA for the CCS program

Using critical thinking and nursing experience evaluate patient’s current condition and assess if member continues to meet the CCS guidelines, review for medical necessity and company standards.

Participate in meetings, conduct provider training in the field across the state of CA.

Conducting complex professional/technical research and analysis for assigned projects.

Complete monthly California Children’s Services health plan logs.

Determining short or long term program goals and setting efficient strategies to achieve them by monitoring progress and evaluating outcomes.

Analyzing and implementing or searching for new ways to improve current program processes for better, effective, and more efficient services.

Create, manage, and update Excel spreadsheets to track various aspects of the CCS authorization process.

Other Nurse Reviewer duties as assigned.

QUALIFICATIONS/SKILLS & KNOWLEDGE REQUIREMENTS

• Valid California Licensed Vocational Nurse License required
• Minimum 1 year Utilization Management experience required
• Minimum 1 year California Children’s Services experience preferred
• High School Diploma (or equivalent) required
• Bachelor’s degree in Health Care Administration preferred

Maren Medical Group, DBA La Salle Medical Associates IPA is a healthcare organization dedicated to serving patients with affordable and compassionate patient care while working with State agencies to help manage patient costs

Company Description

Maren Medical Group, DBA La Salle Medical Associates IPA is a healthcare organization dedicated to serving patients with affordable and compassionate patient care while working with State agencies to help manage patient costs

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