Authorization Review Nurse -LVN

Gonzaba Medical Group; Cassin (TX); On-site; USD 45,000 - 65,000; Full time

Job summary

Gonzaba Medical Group seeks an LVN to join its Utilization Management team in San Antonio, TX. The role focuses on reviewing services for medical necessity, processing authorizations, and communicating determinations to the claims department and health plans.

A strong foundation in ICD-10/CPT-4 coding and HIPAA is required, with 2+ years in managed care preferred. The LVN will work to ensure timely reviews, participate in UM policy updates, and support other GMG departments as needed in a

Qualifications

• LVN certificate required or equivalent licensure.
• 2+ years in Managed Care/Utilization Management preferred.
• Strong knowledge of ICD-10 and CPT-4 coding.
• Excellent verbal and written communication skills.
• Able to work under pressure and meet deadlines.

Responsibilities

• Review and process claims to determine authorization for payment.
• Conduct medical necessity reviews using established criteria.
• Document decisions in EMR and MSO systems.
• Communicate findings to claims department and health plans.
• Participate in UM team meetings and process improvement efforts.

Skills

Nursing

ICD-10 CPT-4

Utilization Management

HIPAA

Communication

Education

LVN Certificate

Tools

MS Office

Job description

Job DetailsJob Location: 933 Pleasanton Rd - San Antonio, TX 78214Position Type: Full TimeJob Category: Referrals

This position has no supervisory responsibilities.

All duties performed will be done accurately and in a timely manner.

Carries out GMG UM Program activities and UM operations. Reviews/ works reports daily that document services discovered in the claims process that do not have appropriate authorization to process the claim. Research services by various means (review of medical record, consult notes, patient input) to evaluate if claims should be authorized for payment or denied based on appropriate guidelines. Summarizes medical record documentation for physician medical necessity reviews as indicated. Supplies evidenced-based criteria to medical necessity reviews and documentations appropriately in review summary. Documents the decision in multiple platforms such as EMR and MSO to communicate the determination to the claims department/health plan. Carries out the process in a timely manner resolving the majority of claims without authorizations within 1-2 working days, more complex determinations within 5 business days. As this impacts Claims processing timeliness. Holds regular “U Status” meetings (U=unauthorized) with referral/MSO team to review complex services, develop consistency in reviews and criteria utilized. Identifies opportunities for operational improvement, and works collaboratively with UM team, Case Management, Referral Department, and other GMG departments. Communicates effectively regarding UM issues with patients, GMG staff/providers and external staff/providers. Participates in the annual review of Managed Care, UM policies and procedures, and other periodic reviews as needed. Promotes the Contracted Network Providers to GMG patients and staff. Promotes teamwork in daily activities. Exercises tact and courtesy when dealing with patients / families, Network staff, Providers and co-workers. Maintains strict confidentiality. Practical HIPAA knowledge and focus. Other duties as assigned.

Qualifications

Education and Experience

Minimum Certificate Degree in Nursing required. Current licensure as a Licensed Vocational Nurse (LVN) Requires at least 2 years’ experience in Managed Care/Utilization Management experience. Must have knowledge of ICD-10 and CPT-4 coding, medical terminology. Must have strong verbal and written communication skills. Able to work efficiently under pressure.

Other Requirements

Computer Skills: Knowledge of Word Processing software, database software, spreadsheet and Internet Software. Able to operate common office equipment.

Work Environment

Depending upon the area assigned, may be 100% clinical setting or office setting in a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.

Mental / Physical Requirements

Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting to 40 lbs. Close vision and ability to adjust focus

Additional Information

Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to our culture and core values.

Other Duties As Assigned

The above job description is not intended to be an all-inclusive list of duties and standards of the position. Team members will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.