📍 Location: Alhambra, CA, US
🏠 Work: On-site
💰 Salary: USD 26 - 32 (hourly)
📝 Description: **Position Summary**
The PACE Utilization Coordinator \\- LVN supports utilization management functions for PACE participants. The position assists with utilization review activities, ensures accurate and timely authorizations, and supports care coordination efforts to deliver quality, cost\\-effective services. This role works under the supervision of the PACE Medical Director and collaborates with the clinical team and external providers.
**Essential Duties and Responsibilities**
* Assist in conducting concurrent and retrospective utilization management reviews.
* Support the review of hospitalizations, post\\-acute care stays, and specialty referrals.
* Track and process referral authorizations within required timeframes.
* Assist with discharge planning and communication with hospitals, skilled nursing facilities, and providers.
* Maintain accurate documentation of utilization management activities in the electronic medical record.
* Provide utilization data and reporting support to leadership and clinical teams.
* Identify and report potential utilization issues and outliers to the Medical Director.
* Serve as a liaison with providers and care managers for service authorization questions.
* Support the denial management and provider appeal process.
* Participate in interdisciplinary team meetings and care coordination discussions.
* Support quality improvement initiatives related to utilization management.
* Maintain current knowledge of PACE utilization requirements, policies, and procedures.
* Assist in identifying high\\-risk participants and escalating care concerns to medical leadership.
**Minimum Qualifications**
* Graduate of an accredited vocational nursing program with a current unencumbered LVN license in the State of California.
* Current BLS certification from the American Heart Association.
* Valid California driver’s license and acceptable driving record.
* Minimum two years of nursing experience with direct patient care coordination.
* Minimum one year of experience working with the frail or elderly population.
* Knowledge of State and Federal healthcare regulations, quality standards, and utilization review principles and guidelines such as Medicare, Medicaid and MCG/InterQual.
* Proficiency with Microsoft Office and electronic medical records.
* Excellent organizational and communication skills.
* Ability to interpret clinical documentation and follow established utilization guidelines.
**Preferred Qualifications**
* Experience with utilization management or care coordination in a PACE or senior care setting preferred.
**Physical Demands and Work Environment**
* Requires standing, walking, occasional pushing, pulling, and lifting.
* Ability to lift up to 30 pounds; assistance required for heavier loads.
* Manual dexterity and visual/hearing acuity required for clinical documentation and communication.
* Exposure to infectious materials and biohazards common in healthcare settings.
* Must be able to communicate with participants, caregivers, and team members, including those with cognitive or physical limitations.
* Moderate stress related to workload, deadlines, and participant needs.
**Direct Reports**
PACE Medical Director
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