Case Manager

1. Reviews all requests for specialty care, elective surgeries, treatment plans and diagnostic studies in accordance with commercial and senior health plan and CMS timelines.
2. Utilizes health plan, CMS, Milliman and Hayes as sources for documenting appropriateness and standard of care. Seeks consultation from IPA Medical Director when request for services does not meet health plan, CMS, Milliman or Hayes recommendations.
3. Seeks to obtain a complete data set about the treatment plan and patient progress. This can include calling the attending physician, discussing therapy with the physical therapist and/or consultation with the primary nurse.
4. Works closely with the Appeal and Denial Unit by providing requested information and completing denial paperwork within timeframes.
5. Channel referrals to contracted providers.


1. LVN or RN
2. Licensure in the State of California
3. LPN with 5 years of acute care experience/RN with 2 years of acute care experience (preferred)
4. 1 year of previous UM experience
5.

Shift Start/End Time: 8am to 5pm

Dress Code: Business Attire


Are there any specific health screens required? TB

Where is the work to be performed? (Please list preferred UHG facility, if other please specify i.e. remote work, rural, etc.) PrimeCare Corona office - 2275 Sampson Ave Suite 111 Corona, CA 92878

Who will be conducting interviews? (Please list names of interviewers) Margo Tavale, Gurwinder Singh

What type of interview process is preferred? (Face to face, phone) Face to Face

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Reference number US_EN_2_108175_334362