We are seeking a highly skilled and detail-oriented LPN Medical Reviewer I to join our team as a Utilization Management Specialist. As a key member of our medical review team, you will be responsible for performing medical reviews, utilization management, and appeals using established criteria sets and clinical guidelines. This is a full-time, remote opportunity after completing 6 months of on-site training, offering a unique chance to work from home and contribute to the delivery of high-quality healthcare services.
Key Responsibilities:
- Perform medical reviews and make reasonable charge payment determinations
- Monitor process timeliness and ensure compliance with contractor standards
- Conduct authorization processes, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines
- Utilize allocated resources to back up review determinations and provide education to members and their families/caregivers
- Participate in quality control activities and maintain accurate documentation of all determinations and basis for each
Requirements:
- Bachelor's degree in Social Work or graduate of an accredited school of Licensed Practical Nursing or Licensed Vocational Nursing
- 2 years of clinical experience
- Active, unrestricted LPN/LVN licensure from the United States and in the state of hire
- Working knowledge of word processing software and good judgment, customer service, and organizational skills
Preferred Qualifications:
- Associate Degree in Nursing or graduate of an accredited school of nursing
- Working knowledge of spreadsheet and database software
- Demonstrated oral and written communication skills and ability to persuade, negotiate, or influence others
What We Offer:
- Comprehensive benefits package, including subsidized health plans, dental and vision coverage, 401k retirement savings plan, and life insurance
- Paid Time Off (PTO) and education assistance
- Opportunities for professional growth and development in a diverse and inclusive workplace
How to Apply:
If you are a motivated and detail-oriented individual with a passion for delivering high-quality healthcare services, please submit your application, including your resume and a cover letter, to be considered for this exciting opportunity.
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