Medical Case Manager (LVN) Long Term Care

Job Description

We are looking for a detail-oriented Medical Case Manager (LVN) specializing in CalAIM and Long Term Care (LTC) to join our team at Sunshine Enterprise USA LLC. In this role, you will be responsible for processing and authorizing medical service requests, ensuring compliance with established criteria and procedures. Working closely with health professionals and providers, you will play a key role in coordinating member care and maintaining quality standards.

Responsibilities

• Review and process requests for medical services in compliance with CalAIM and LTC criteria.
• Verify and process referrals using established protocols for medical necessity.
• Coordinate member care with health networks and providers.
• Ensure timely documentation and data entry for all authorizations and referrals.
• Assist in identifying areas for staff training and support the Long-Term Care manager.

Requirements

• High School diploma or equivalent.
• Current LVN license in California.
• Minimum 3 years of nursing experience with 1 year in Clinical Nurse Review.
• Strong problem-solving and organizational skills.
• Ability to communicate effectively and work in a fast-paced environment.

Preferred Qualifications

• Managed care and concurrent review experience.
• Bilingual proficiency in English and one of the following: Arabic, Farsi, Chinese, Korean, Spanish, or Vietnamese.

Knowledge of

• Utilization management guidelines and regulations.
• Medical terminology and coding systems (CPT-4, ICD-10, HCPCS).
• Medi-Cal and Medicare benefits.
• Healthcare practices and resources.

Benefits

• Competitive salary range: $33,000 - $54,930 yearly.
• Health, dental, vision, and life insurance.
• 401(k) savings plan.
• Awards and recognition programs.

If you are passionate about healthcare, possess the required qualifications, and are eager to make a difference in medical case management, we encourage you to apply and join our team at Sunshine Enterprise USA LLC.