LVN - Utilization Management
Pre and Post Service Clinical Review
Monterey Park, CA
Day to Day Responsibilities:
- Pre and Post Service Clinical Review RN/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.
- 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 standard
- 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 necessar
- 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.
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
SHIFT: 8-10 hours days - 9:00am-6:00pm (40-50 Hours per week)
Location: Remote and onsite in Monterey Park (a mixture of both)