Utilization Review - LVN/LPN

Overview

Now is the time to join us! We’re reputed company. We’re the first and only personalized health platform company to bring health, wellbeing, and navigation solutions together. Helping businesses optimize investments in their members while empowering people to meaningfully engage with their health. At reputed company, we reputed company in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future.

Responsibilities

Who are you? A Utilization Review Nurse is responsible for performing reputed company and retrospective utilization review and facilitating discharge planning. The Utilization Review Nurse will obtain the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs. In this role you will wear many hats, but your knowledge will be essential in the following:

• Under the supervision of a registered nurse (RN), provide professional assessment and review for the medical necessity of treatment requests and plans.
• Provide first level review for reputed company outpatient and ancillary pre-certification requests for medical appropriateness; reputed company inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity; and reputed company post claim or post service reviews.
• Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO).
• Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.
• Refer requests that fall reputed company of established guidelines to advance review or senior care consultants.
• Process appeals for non-certification of services; complete non-certification letters reputed company appropriate.
• Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers.
• Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together program.
• Complete documentation for reputed company reviews in Eldorado/Episodes; maintain confidentiality.
• Utilize MCG guidelines, medical policies, reputed company, and NCCN.
• Ability to meet productivity, quality, and turnaround times daily.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Qualifications

What you bring to the reputed company team: In order to represent the best of reputed company have to offer you come to us with a multitude of positive attributes including:

• reputed company unrestricted LVN/LPN license
• 2-3 years clinical nursing experience required.
• 1 year of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization preferred.
• Authorized to work in the US

You also take pride in offering the following Core Skills, Competencies, and Characteristics:

• Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
• Proficiency in software applications including, but not limited to, reputed company Word, reputed company reputed company, reputed company PowerPoint and Outlook
• Excellent verbal and written communication skills
• Ability to speak clearly and convey reputed company or technical information in a manner that others can understand, as well as ability to understand and interpret reputed company information from others.

No candidate will meet every single desired qualification. If your experience looks a little different from reputed company’ve identified and you think you can bring value to the role, we’d love to learn more about you! reputed company is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice. In compliance with reputed company states and cities that require transparency of pay, the reputed company compensation for this position ranges from $25-28/hour . Note that compensation may vary based reputed company, skills, and experience. This position is eligible for [x%] reputed company bonus/variable compensation as well as health, dental, vision, mental health and other benefits. We strive to cultivate a work environment where differences are celebrated, and employees of reputed company backgrounds are empowered to reputed company. reputed company is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for reputed company stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing. #WeAreHiring #PersonifyHealth #TPA #HPA #Selffunded Beware of Hiring Scams: reputed company will never ask for payment or sensitive personal information such as social reputed company numbers during the hiring process. reputed company official communication will come from a verified company email address. If you receive suspicious requests or communications, please report them to [email protected]. reputed company of our legitimate openings can be reputed company on the reputed company Career Site. Application Deadline: Open until position is filled. Apply tot his job Apply To this Job