Utilization Review Specialist LVN Remote

About This Role

Conduct medical reviews and benefit verification for healthcare services, ensuring compliance with medical necessity criteria and regulatory requirements. Serve as a liaison for providers and appeals processes within a leading health care organization.

Responsibilities

• Conduct medical reviews, benefit verification, and apply criteria to determine medical necessity for health care services
• Serve as a liaison in reviewing requests for medical and surgical procedures, services, and admissions
• Communicate with providers regarding pertinent information needed for medical review to ensure service decisions are determined within appropriate timeframes
• Serve as a liaison to the Grievance and Appeals Department for Medicare Advantage appeals
• Complete and review denial letters in accordance with TDI and/or CMS and health plan requirements
• Serve as liaison and primary point of contact for add-on procedures performed at the KS Ambulatory Surgery Center (ASC)
• Support Utilization Review quality assurance initiatives, including mock audits, to ensure compliance
• Adapt to changes in policies and procedures, new techniques, and additional responsibilities

Requirements

• Licensed Vocational Nurse
• Active Texas RN license or multistate compact RN license
• 5+ years of utilization review experience at a health plan, ACO, IPA, or provider group
• HMO, PPO, and POS insurance knowledge

Qualifications

• 5+ years of utilization review experience

Nice to Have

• CEU requirements maintained
• Active Driver's License
• Certification in area of specialization
• Bilingual
• Experience working with insurance (HMO, PPO, and POS) companies to obtain authorizations and pre-certification for medical services
• Excellent verbal and communication skills
• Organizational skills
• Consistent and prompt attendance at employer worksite

Benefits