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Utilization Management LVN - Non Patient Facing

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

LVN - Utilization Management

Pre and Post Service Clinical Review

Monterey Park, CA

Pay $25.00-$30.00/hour


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.

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 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)

Company Description
Finding a dream job can feel a lot like searching for a needle in a haystack. We start by viewing each candidate as an individual, identifying their distinct strengths and guiding them to the right opportunities. We're also big believers in mentoring our candidates and creating long-term relationships. Helping you find your dream job is really just the start. We want to help you build a dream career!

Wollborg Michelson Recruiting


Monterey Park, CA