PACE Utilization Specialist LVN (Central Valley PACE - Merced)
PACE Utilization Specialist LVN (Central Valley PACE - Merced)
Posted on :
14-06-2025
Employer Active
1 Vacancy
Job Alert
You will be updated with latest job alerts via emailValid email field required
Send jobs
Share
Send me jobs like this
Job Alert
You will be updated with latest job alerts via emailValid email field required
Send jobs
Job Description
Under the direct supervision of the Utilization Management (UM) Registered Nurse (RN) the PACE Licensed Vocational Nurse (LVN) assists in assessing the need for and delivering clinical skilled services. Provides utilization management functions as a part of the Program of All-Inclusive Care for the Elderly benefits management system. This includes providing utilization review and management for all acute post-acute and outpatient services as well as performing the identification analysis and resolution of resource utilization outliers consistent with established protocols policies and procedures.
Schedule is Monday Friday 8:00am 5:00pm
Compensation:
$32.55 - $34.17 an hour.
Duties and Responsibilities
- Assists in performing concurrent and retrospective utilization management reviews and functions; collect analyze and report outcomes to internal and external stakeholders.
- Collaborate with the UM RN Health Plan Director Director of Center Operations Clinical Manager RN and Interdisciplinary Team (IDT) to ensure appropriate initial and ongoing service authorization for post-acute participant stays.
- Performs concurrent review process in order to effectively manage the length of inpatient and post-acute stays consistent with participant goals of care and care plan.
- Serve as a resource for UM RN and network provider care managers to ensure consistent and accurate level of care and service authorization for appropriate claim submission and payment.
- Maintains professional relationships with internal and external stakeholders including provider community while identifying opportunities for utilization management process improvement;
- Identify high-risk patient Emergency Department (ED) utilizers provider referral patterns utilization management referrals and disease registry reporting mechanisms and refer to appropriate PACE site medical leadership.
- Maintains up-to-date knowledge of PACE rules and regulations governing utilization management processes; implements approved policies procedures and workflows.
- Ensures timely referral processing by tracking within the authorization system and coordinating with internal and external stakeholders.
- Responsible for daily coverage needs for inpatient concurrent reviews discharge planning utilization management authorization request review and ensures patients meet appropriate level of care based on acceptable evidence-based clinical criteria(s).
- Assist in the oversight and coverage needs for daily review and processing of referral authorizations in accordance with turnaround time standards set by PACE regulations requirements.
- Alerts the UM RN of noticed changes in participants condition.
- Review medical records for each participant on-going services and services received within past year using Electronic Medical Record (EMR) plan of care for the upcoming year using EMR and IDT annual assessments to assist in ensuring continuing skilled needs are identified.
- Assist the Supervising RN with current medical status and functional capabilities for each participant.
- Supervise Patient Care Assistants in accordance with regulations.
- Assess patients physical and mental wellbeing report to provider or RN.
- Attend and participate in staff meetings in-services projects and committees as assigned.
- Be flexible in schedule of hours worked.
- Participates in IDT meetings as necessary.
- Other duties as assigned.
Physical Demands
- Requires standing walking occasional pushing pulling and lifting.
- Ability to lift up to 30 pounds. Moving or lifting greater than 30 pounds should be done with assistance as appropriate.
- Requires manual and finger dexterity and eye-hand coordination.
- Requires corrected vision and hearing to normal range with or without reasonable accommodation.
- Must be able to communicate verbally with all staff caregivers participants and community at large.
- Ability to interact professionally and respectfully with geriatric individuals including those with cognitive decline and/or physical frailties.
- Requires working under stressful conditions.
- Moderate pressure to meet scheduled appointments while dealing with frail and confused participants.
- Subject to participants that may have the potential for verbal or physical aggression.
Work Environment
- Exposure to biohazards including infectious material and waste and any other conditions common in a health care environment.
- Subject to unpleasant odors
- The noise level is usually quiet to moderate but may at times be noisy and crowded.
Education/Experience Requirements
Minimum Qualifications
- Valid CA Drivers License acceptable driving record and vehicle insurance.
- Detailed-oriented and organized.
- Excellent written and verbal communication skills with specific ability to maintain accurate records.
- Excellent customer service skills.
- Must have integrity practice discretion and practice objective problem solving.
- Ability to collect organize manage and report on large volumes of meaningful data for decision making while using spreadsheets or other data processing software.
- Knowledge of basic statistical principles.
- Skilled in establishing and maintaining effective working relationships with participants coworkers medical staff and the public.
- Skilled in identifying and recommending problem resolution.
- Knowledge of safety and infection control requirements for healthcare facilities.
- Demonstrated experience in quality assurance and performance improvement activities.
- Proficient in Microsoft Office applications; advanced Microsoft Excel experience required.
- Knowledge of State and Federal healthcare regulations.
- Only act within the scope of authority to practice.
- Meet a standardized set of competencies for the specific position description established by Central Valley PACE and approved by CMS before working independently.
Education/Experience
- Current BLS CPR Card certified by American Heart Association.
- High School diploma or equivalent.
- Graduate of an accredited school of professional nursing.
- Current unencumbered Licensed Vocational Nurse (LVN) in the state of CA.
- Minimum two (2) years nursing experience with direct patient care coordination with Home or Community Health Provider experience within the last (3) years required.
- Minimum one (1) year experience working with the frail or elderly population.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
Key Skills
Report This Job
Disclaimer: Drjobpro.com is only a platform that connects job seekers and employers. Applicants are advised to conduct their own independent research into the credentials of the prospective employer.We always make certain that our clients do not endorse any request for money payments, thus we advise against sharing any personal or bank-related information with any third party. If you suspect fraud or malpractice, please contact us via contact us page.
