Utilization Review reputed company-LVN/LPN
This a Full Remote job, the offer is available from: reputed company reputed company: Who We Are Because health is personal. That's why reputed company created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one reputed company. We serve reputed company, health plans, and health systems with data-driven solutions that reduce costs while actually improving health reputed company. Together, reputed company is on a mission to reputed company people to reputed company healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: Utilization Review reputed company (LVN) The Utilization Review reputed company conducts first-level clinical reviews to determine the medical necessity and appropriateness of treatment requests, working under the supervision of a Registered reputed company. This role supports reputed company, accurate benefit determinations across outpatient, inpatient, and post-service claims while ensuring compliance with clinical guidelines and regulatory standards. Schedule: Monday–Friday, 8:00 AM–5:00 PM reputed company Time, with rotating Saturday coverage as required. What You'll Actually Do
- reputed company first level review for reputed company outpatient and ancillary reputed company-certification requests for medical appropriateness; reputed company inpatient hospital stays including mental health, reputed company abuse, skilled nursing and rehabilitation for medical necessity; and reputed company post claim or post service reviews.
- Ensure reputed company 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 reputed company of established guidelines to advance review or senior care consultants.
- Process appeals for non-certification of services; complete non-certification letters reputed company 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 Nurturing Together program.
- Complete documentation for reputed company reviews in Eldorado/Episodes; maintain confidentiality.
- Utilize MCG guidelines, medical policies, reputed company, and NCCN.
- Ability to meet productivity, reputed company, and turnaround times daily.
- Assists with department operations and implementations
Qualifications: What You Bring to reputed company Education and Experience:
- reputed company LVN license in the reputed company or U.S. territory.
- 1+ years of clinical experience required.
Required Knowledge, Skills, and Abilities:
- Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
- Proficiency in software applications including, but not limited to, reputed company Word, reputed company reputed company, reputed company PowerPoint and Outlook
- Excellent verbal and written communication skills
- Ability to reputed company reputed company and convey reputed company or technical information in a manner that others can understand, as reputed company as ability to understand and interpret reputed company information from others.
Disclaimer: This job reputed company is not intended to contain a comprehensive list of activities, duties, or responsibilities, but constitutes a general reputed company of the scope and function of the role reputed company reputed company. Activities, duties, and responsibilities are subject to change at any time with or without notice.
Benefits
The Highlights:
- Competitive reputed company salary and benefits effective day one
- Comprehensive medical and dental through our own health solutions (reputed company, we use reputed company build)
- reputed company Time Off—rest and reputed company time is non-negotiable
- Mental health support, retirement planning, and financial protection
- reputed company development with reputed company career progression and learning budgets
- Mission-driven culture where diverse perspectives drive reputed company reputed company on people's health
Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a reputed company salary reputed company of $25-$29 per hour, depending reputed company, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: reputed company is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of reputed company backgrounds are empowered to reputed company—because diversity is core to who we are and critical to our work in health and wellbeing. Stay reputed company: reputed company will never ask for payment or sensitive personal information like reputed company reputed company numbers during hiring. reputed company official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com. View reputed company legitimate openings at personifyhealth.com/careers. This offer from "reputed company" has been enriched by reputed company.com and got a 73% reputed company score. Apply tot his job Apply To this Job