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Utilization Review LVN

Dignity Health Medical Foundation Rancho Cordova, California
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The posted compensation range of $29.16 - $42.28 /hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.

Requisition ID 2025-395222 Employment Type Full Time Department Utilization Review Hours/Pay Period 80 Shift Day Weekly Schedule Monday- Friday 8-5 Remote No Category Case Management and Social Work
Overview

Dignity Health Medical Foundation established in 1993 is a California nonprofit public benefit corporation with care centers throughout California.  Dignity Health Medical Foundation is an affiliate of Dignity Health – one of the largest health systems in the nation - with hospitals and care centers in California Arizona and Nevada. Today Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers we provide increasing support and investment in the latest technologies finest physicians and state-of-the-art medical facilities. We strive to create purposeful work settings where staff can provide great care while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled qualities that are vital to maintaining excellence in care and service.


Responsibilities

***This position is hybrid in-office/clinic and work from home.

Position Summary:


The Utilization Review (UR) LVN uses clinical judgement in providing utilization management (UM) services. The focus is to provide high quality cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary. The LVN assists in determining appropriateness quality and medical necessity of referral requests using pre-established guidelines. This position supports the Medical Group in effective management of the managed care patient. This position may be assigned cases in pre-authorization areas in skilled nursing facility review or in concurrent review.

Responsibilities may include:
- Conducts pre-authorization referral reviews following workflow as written document criteria to make determination or recommendation and process the referral in a timely manner.
- The LVN supports the quality programs within the Department through participation in projects reviews and compliance with policies and practices.
- The LVN provides appropriate support to co-workers leaders physicians referral sources and other departments during all work activities.


Qualifications

Minimum Qualifications:


- 3 years Utilization Management (UM) experience. 5 years LVN experience.
- Clear and current CA LVN license.
- Knowledge of health plans. Medical specialty procedures and diagnoses.
- Strong knowledge nursing requirements in a clinical setting. Knowledge of utilization management programs as related to pre-set protocols and criteria.
- Ability to work within an interdisciplinary structure and function independently in a fast paced environment while managing multiple priorities and meeting deadlines.
- Ability to apply clinical judgment to complex medical situations and make quick decisions.
- Ability to read and interpret benefit contract specifications.
- Ability to understand and follow established criteria and protocols used in managed care functions.
- Strong organizational skills.
- Effective telephone and computer data entry skills required.
- Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses.

Preferred Qualifications:


- General knowledge of UM and Managed Care preferred.
- Use of InterQual guidelines preferred.
- Experience at meeting deadlines by prioritizing work flow preferred.
- Physician group experience preferred.
- Knowledge of California health plans and differences between commercial and advantage plans preferred.
- Familiarity with business practices and protocols with ability to access data and information using automated systems preferred.

- Ability to communicate effectively with coworkers, members, their families, physicians and health care providers preferred.

#CareCoordination

Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.

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Depending on the position offered, CommonSpirit Health offers a generous benefit package, including but not limited to medical, prescription drug, dental, vision plans, life insurance, paid time off (full-time benefit eligible employees may receive a minimum of 14 paid time off days, including holidays annually), tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings, as may be amended from time to time. For more information, please visit https://www.commonspirit.careers/benefits.

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Equal Opportunity

CommonSpirit Health™ is an Equal Opportunity/Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please click here [PDF].

CommonSpirit Health™ will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c). External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances. If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA). CommonSpirit Health™ participates in E-Verify.