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Utilization Management Nurse LVN/LPN (20-04638)

Iconma Monterey Park ,CA
  • Expired: over a month ago. Applications are no longer accepted.
Job Description

Pre and Post Service Clinical Review LVN - Ensures accurate and timely prior authorization of designated healthcare services and timely and accurate clinical claim review of designated healthcare services. Pre & Post Service Clinical Review Nurse preforms first level determination approvals for members using criteria guideline hierarchy, policies and nationally recognized clinical criteria across lines of business. Successful RN/LVN candidates will review prior auth and post service clinical claim review requests for medical necessity, coding accuracy and criteria guideline compliance. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions is required.

Essential Responsibilities:
- Ensures proper procedure and diagnosis codes is reviewed for submitted procedures/claims.
- Solicits support from SME's, leads, supervisors and managers as appropriate
- Triages and prioritizes cases to meet required turn-around times
- Expedites access to appropriate care for members with urgent needs
- Prepares and submits clinical review cases to Medical Director (MD) for medical director oversight and necessity determination
- Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements
- Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
- Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
- Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary
- Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives. Other duties as assigned.

Qualities:
General Knowledge & Experience Required:
- Current CA RN/LVN License.
- Bachelors of Science in Nursing or advanced degree preferred
- Requires practical knowledge of job area typically obtained through advanced education combined with experience.
- Prior experience with CMS (Medicare and Medi-Cal) business
- Knowledge of NCQA and federal and state requirements highly desirable.
- Typically, requires a college degree or equivalent experience and 3 years of prior relevant experience.
- Knowledge of CPT-4, ICD-10, HCPCs and provider billing practices
- Demonstrate the ability to act independently using sound clinical judgement
- Experience in a fast paced, production and quality environment preferred
- Demonstrated efficient, time management techniques and skills
- Able to handle multiple tasks simultaneously while prioritizing cases to meet regulatory and business based turn around times

Internal/External Groups with which the Candidate will interface with:
Managers, co-workers and providers.

Education Requirement:
High School Diploma; LVN/RN State of California License

Company Description
ICONMA is a certified Woman-Owned nationwide consulting firm providing Professional Staffing and Project Based Services and Solutions for Fortune 1000 clients in a broad range of industries.

Our areas of expertise include Information Technology, Engineering, Accounting/Finance, Scientific/Clinical, Professional, Mortgage, Administrative/Clerical, Call Center, Human Resources, and Marketing/Creative. ICONMA has a nationwide presence that helps us support our national clients. For more information, please visit us at www.iconma.com.

Iconma

Why Work Here?

Working with top-notch clients!!

ICONMA is a certified Woman-Owned nationwide consulting firm providing Professional Staffing and Project Based Services and Solutions for Fortune 1000 clients in a broad range of industries. Our areas of expertise include Information Technology, Engineering, Accounting/Finance, Scientific/Clinical, Professional, Mortgage, Administrative/Clerical, Call Center, Human Resources, and Marketing/Creative. ICONMA has a nationwide presence that helps us support our national clients. For more information, please visit us at www.iconma.com.

Address

Monterey Park, CA
USA