LVN , Preservice Review Nurse - Remote - 2247530 El Segundo, CA 10/11/2024 Nursing
About the position
The Prior Authorization LVN plays a crucial role in ensuring timely completion of prior authorization requests from patients and providers, adhering to contractual and regulatory requirements. This position promotes quality and cost-effective medical care by applying clinical acumen and utilizing nationally recognized guidelines. The LVN will also assist management and compliance teams in audits and regulatory activities, contributing to the overall efficiency of healthcare services.
- Responsibilities
- Screen and review prospective, concurrent, and retrospective referrals and authorizations for medical necessity and appropriateness of service. ,
- Coordinate health care services with physicians, facilities, contracted providers, and community resources. ,
- Determine appropriateness of denial and draft denial language based on standardized UM criteria. ,
- Coordinate out-of-network and out-of-area cases with members and health plans. ,
- Review patient referrals within specified care management policy timeframes. ,
- Develop and maintain effective working relationships with physicians and office staff. ,
- Understand cost consequences of care management decisions using appropriate reports. ,
- Maintain effective communication with health plans, physicians, hospitals, and patients.
- Requirements
- Graduation from an accredited Licensed Vocational Nurse program. ,
- Active, unrestricted LVN license in the state of California. ,
- 2+ years of clinical experience in an acute or ambulatory patient care setting, including one year in a managed care environment. ,
- Ability to work 8-5 PM PST.
- Nice-to-haves
- 3+ years of experience working as an LVN/LPN. ,
- 2+ years of care management, utilization review, or discharge planning experience. ,
- Experience in an HMO or Managed Care setting.
- Benefits
- Comprehensive benefits package ,
- Incentive and recognition programs ,
- Equity stock purchase ,
- 401k contribution
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