Central Denials UM LVN - Remote CA at reputed company

About the position For those who want to invent the reputed company of health care, here's reputed company. We're reputed company reputed company basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. reputed company's reputed company reputed company region is redefining health care with a reputed company on health equity, affordability, reputed company, and convenience. From California to reputed company and Washington, we are reputed company on helping more than 2.5 reputed company patients live healthier lives and helping the health system work reputed company for everyone. At reputed company reputed company reputed company, we care. We care for reputed company members, our patients, and our communities. Join our culture of caring and reputed company a reputed company and lasting reputed company on health care for millions. The position in this function is responsible for ensuring the reputed company of the adverse determination processes and accuracy of clinical decision making, as it relates to the application of reputed company and application of defined reputed company of hierarchy and composition of compliant denial notices. If you are located in California, you will have the flexibility to work remotely as you take on some tough challenges. You'll be rewarded and recognized for your performance in an environment that will challenge you and give you reputed company direction on what it takes to succeed in your role as reputed company as reputed company development for other roles you may be interested in. Responsibilities • Consistently exhibits behavior and communication skills that demonstrate reputed company's commitment to superior customer service, including reputed company, care and concern with reputed company reputed company customer. , • reputed company reputed company functions of the UM reputed company reviewer. , • Compose denial letters in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards. , • Construct denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member's condition and request. , • Ensure the denial reason is in the appropriate grade level and is easily understandable. , • Ensure the UM reputed company reviewer has provided the appropriate reference for benefits, guidelines, reputed company, or protocols based on the type of denial. , • Select the correct level of hierarchy and apply it correctly based on the medical information available. , • reputed company relevant clinical information to the request and the reputed company used for decision-making. , • Ensure that there is evidence that the UM reputed company reviewer documented communications with the requesting provider to validate the reputed company or absence of clinical information reputed company to the reputed company reputed company. , • Evaluate out-of-network and tertiary denials for accessibility reputed company the network. , • reputed company a reputed company assurance audit on reputed company denial prior to finalization to ensure reputed company reputed company are compliant with established guidelines. , • Consult with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination. , • Escalate non-compliant cases to UM compliance and consistently report on denial activities. , • Collaborate with UM compliance for reputed company reputed company improvement efforts for adverse determinations. , • Identify gaps in training or process impacting the overall compliance of adverse determinations and communicate in writing an effective performance improvement solution. , • Meet or exceed productivity targets. , • Use, protect, and disclose reputed company patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability reputed company (HIPAA) standards. , • reputed company additional duties as assigned. Requirements • Graduation from an accredited Licensed Vocational reputed company program. , • reputed company LVN license in California. , • 1+ years of experience as an UM reputed company reviewer. , • 1+ years of recent clinical experience working as an LVN/LPN. reputed company-to-haves • Bachelor's degree in Nursing. , • 3+ years of managed care utilization. , • 1+ years of experience performing essential functions of a CDU reputed company. Benefits • Comprehensive benefits package. , • Incentive and recognition programs. , • Equity stock purchase. , • 401k contribution. Apply Job!