Job description

ESSENTIAL DUTIES and RESPONSIBILITIES:

Under the supervision of a registered nurse (RN), provide professional assessment and review for the medical necessity of treatment requests and plans.

· Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity; and all post claim or post service reviews.

· Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO).

· Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.

· Refer requests that fall outside of established guidelines to advance review or senior care consultants.

· Process appeals for non-certification of services; complete non-certification letters when appropriate.

· Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers.

· Identify and refer potential cases to case management, wellness, chronic disease and M2B programs.

· Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality.

· Utilize MCG guidelines, medical policies, up to date, and NCCN.

· Ability to meet productivity, quality, and turnaround times on a daily, weekly and monthly requirements.

KEY COMPETENCIES:

· Knowledge of medical claims and ICD-10, CPT, HCPCS coding.

· Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook

· Excellent verbal and written communication skills

· Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.

QUALIFICATIONS:

· Current LVN license in the United States or U.S. territory.

· 1+ years of clinical experience required.

· Strong critical thinking skills

· Innovative thinking

Physical and Mental Requirements:

· Ability to safely and successfully perform the essential job functions with or without a reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.

· Ability to maintain regular, punctual attendance.

· Ability to sit for 6-8 hours.

· Constant use of computer keyboard and mouse; repetitive use of both hands.

· Occasional to frequent twisting of neck; occasional bending of neck and at waist.

This job description is not an exclusive or exhaustive list of all job functions that an employee in this position may be asked to perform. Duties and responsibilities can be changed, expanded, reduced or delegated by management to meet the business needs of HealthComp.

Job Type: Full-time

Pay: $80,000.00 - $85,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• Day shift
• Monday to Friday

Experience:

• Utilization review: 4 years (Preferred)

License/Certification:

• LVN (Preferred)

Work Location: Remote

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