Join a team of caring, compassionate Nurses at MemorialCare whose dedication has earned them the highly coveted Magnet® recognition for excellence in nursing and patient care across all of our facilities. The Registered Nurse provides a high level of professionalism, compassion and commitment to our patients by providing safe, efficient patient care through the health experience. MemorialCare Nurses exude the highest standards for nursing excellence, quality patient care, professional innovation and inter-professional collaboration.
- Full-Time, Part-Time, Per-Diem
- Southern California
- Level: Mid, Senior
- Glassdoor Reviews and Company Rating
Success Profile
What makes a successful RN at MemorialCare? Check out the traits below to see if you have the right mix.
- Collaborative
- Communicator
- Compassionate
- Flexible
- Multi-tasker
- Team player
"I’ve worked at Long Beach Medical Center for almost 20 years, the majority of which has been spent as a bedside RN. With the support of the organization I was able to attain my Bachelor’s and then Master’s Degree by participating in the Tuition Reimbursement program. I’ve always felt one of the best things about Nursing is that I learn something new almost every day. I recently became a Clinical Educator and am finding it incredibly rewarding to not only facilitate education for others, but to continue building my own knowledge base with each new opportunity. These hallways have seen me say goodbye to loved ones, hold my baby for the first time, make life-long friends, and advance my career. My heart is where my home is, and my home is here!"
Benefits
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Healthcare
Medical, Dental and Vision plans (HMO & PPO) & Flexible Spending Accounts (FSA)
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Health and Wellness Programs
MemorialCare is committed to providing an environment and culture that empowers its employees to maintain or improve well-being through our nationally recognized "Good Life" program.
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Employer Matching 401(K)
MemorialCare is committed to your financial success and provides the 401(k) Plan to help you save for retirement.
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Professional Development
MemorialCare encourages and supports the professional growth of its employees by providing financial assistance to further their education.
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Paid Time Off
A fully integrated PTO plan which includes; vacation, sick leave, holidays & personal days.
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Life and Disability Insurance
Basic Life/AD&D is an employer paid benefit that is offered to Full-Time employees.
Responsibilities
Location:
Schedule: Per Diem
Shift: Regular
Job Listing:MEM007924
Title: LVN Utilization Review
Location: Fountain Valley
Department: Outpatient Utilization Management
Status: Per-diem
Shift: Days
Pay Range*: $40.00/hour
At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. Memorial Care stands for excellence in Healthcare. Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.
Position Summary
Essential Functions and Responsibilities of the Job
1.Alongwithphysicianhospitalists/PCPs / Specialists,leadsandcoordinatesactivitiesof interdisciplinarytreatmentteamrequiredtomakecomplexclinical,benefitandnetworkdecisions.
2.Analyzedatatoidentifyunder/overutilization;improveresourceconsumption;promotepotential reductionincost;andenhancequalityofcareconsistentwithMemorialCareMedicalFoundation strategicgoalsandobjectives.
3.Apply Utilization ReviewManagementprocesstoensurecontinuityofcarethroughoutthehealthcare continuumincludingreviewandauthorizationofservicesapplyingevidence-basedguidelinesand perMemorialCareMedicalFoundationpolicy.
4.Assuresreviewturnaroundtimesadhereto timelinessstandardssetbycontractingandregulatory requirementsandestablishedproductivityandqualityguidelines.
5.Decisionsanddocumentationdemonstrateprudentutilizationofresources,identifies forpotentialcostreduction;promotequalitycareandcomplywithregulatory guidelinesneededtomaintaindelegatedstatusfromcontractedhealthplans.
6. Assists with developingcorrectiveactionplans,createpoliciesanddesignworkflowsthatoperationalize improvementsidentifiedthroughdata and leadershipanalysis.
7.Documentsdecisionsthatdemonstrateindependentjudgment,criticalthinkingandapplicationof complexmanagedcareregulationsincludingbut notlimited tobenefitstructures, health plan coverage, medicalnecessity,networkcontract,financialresponsibilityandcaremanagement.
8.Implementandmaintainsystemsandprocessesthatmeetvariousregulatoryrequirements.
9.Interpretsandappliesdelegationagreements,divisionsoffinancialresponsibility,contracted providerlists,evidenceofcoverage,healthplanoperationsmanuals,and MemorialCareFoundationpolicy.
10.Independentlyresearchanddeterminetheinformationnecessarytosatisfyspecificbusinessand regulatorymedicalmanagementrequirements. Initiateandcompletethedenialprocessforall servicesdeemedtobe non-coveredbenefitsornot medicallynecessary.
11.May be called upon to participateinregulatorycomplianceauditrequirementsandactivities/committeesincludingbutnotlimited toUtilizationManagement,QualityImprovementand PerformanceImprovement.
12.Maintainanddemonstrateacompleteunderstandingofownscopeofpracticeoflicensure and educationlevel.
13.Monitorsutilizationandprovidesrecommendationsforimprovementagainstestablishedindustry standardsandperformancemeasurementmetrics.
14.Works with Managers to overseeapproval,denial andappealprocess,includingimplementationofappropriatedenialletter languagetomeetregulatorystandards.
15.ParticipatesinContractingandProviderRelationsactivitiesasnecessarytodevelopandmaintainprovidernetworks.
16.Subjecttostandardmedicalmanagementperformancemeasurementsforspecificarea/team includingbut notlimitedtoreferralturnaroundtimes,volume,deniallanguageandoverturnrates.
17.May be required to travel during shift for meetings and staff oversite.
18.May be required to work remote to meet business needs for regulatory compliance.
*Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare—that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there’s more...Check out our MemorialCare Benefits for more information about our Benefits and Rewards.
Experience
- Minimum 2 years of utilization / care management experience applying evidence-based criteria
- Experience performing medical management (UM) in electronic referral application preferred.
- Navigation of Share Point or equivalent experience navigating internal company intranet preferred.
- 2 years’ work experience in Microsoft Word, Microsoft Excel and Microsoft Outlook preferred
Education
- California Licensed Vocational Nurse required
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