Claims Review Nurse, LVN (Remote)

Inland-Empire-Health-Plan-; Rancho Cucamonga (CA); Remote; USD 64,000 - 83,000; Full time

Benefits offered by this job

Competitive salary

On-site fitness center

Medical, dental, vision insurance

Life, short/long-term disability

Career development

Wellness programs

FSAs

CalPERS retirement

457(b) plan with match

Life insurance for employees

Pet insurance

Job summary

Inland Empire Health Plan is seeking a Claims Review Nurse, LVN to perform timely medical reviews of facility and professional claims. You will identify improvements in the UM/Claims interface and support clinical determinations under supervision, helping IEHP meet quality goals.

The role requires an active CA LVN license and at least one year of related experience in utilization, case management or claims auditing. Telecommute option may apply in this role.

Qualifications

• Minimum of one year of relevant work experience.
• Recent experience with inpatient and outpatient utilization and case management.
• Experience in auditing claims; reviewing inpatient medical records and claims preferred.
• Active, unrestricted LVN license issued by the CA Board.
• Associate degree in health care or related field preferred.

Responsibilities

• Audit medical necessity claims in accordance with departmental policies and procedures.
• Act as the key clinical interface between the Claims and Medical Services departments.
• Attend UM and Claims team meetings.
• Review inpatient and outpatient claims that require authorization, appeals and other disputed claims to meet regulatory requirements.
• Obtain the clinical information necessary to make authorization decisions for unauthorized claims.
• Identify potential denied services/admissions/days and present to Medical Director for appropriate decision.
• Review medical records to determine if charges/services are appropriate (CPT/HCPCS codes, up-coding, etc.).
• Analyze level of care on in-patient reviews and track billing trends by provider for leadership review.
• Develop and sustain positive working relationships with physicians, nurses, ancillary staff, and claims personnel.
• Inform staff for coordination of financial arrangements for non-contracted/fee-for-service providers.
• Provide reports as necessary.
• Adapt to changes to promote cooperation and minimize disruption.
• Perform any other duties to ensure health plan operations.

Skills

LVN license

Clinical review

Data analysis

Communication

Auditing claims

Education

Associate degree in health care or related field

High school diploma or GED

Tools

MS Word

Excel

Job description

Overview

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Reporting to the Supervisor, Integrated Transitional Care, the Claims Review Nurse, LVN is responsible for conducting timely medical reviews of IEHP facility and professional claims and appeals. The Claims Review Nurse, LVN identifies process improvements in the UM/Claims interface and makes recommendations to improve the claim authorization process and business rules between Claims and UM teams. The Claims Review Nurse, LVN exercises independent judgment in conducting claims reviews and supports key clinical determinations in alignment with guidance from the Supervisor, Integrated Transitional Care.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Additional Benefits

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

Key Responsibilities

• Audit medical necessity claims in accordance with departmental policies and procedures
• Act as the key clinical interface between the Claims and Medical Services departments
• Attend UM and Claims team meetings
• Review inpatient and outpatient claims that require authorization, appeals and other disputed claims in a timely manner to meet regulatory requirements
• Obtain the appropriate clinical information necessary to make authorization decisions for unauthorized claims
• Identify potential denied services/admissions/days and present to the Medical Director, both Plan and Direct, for appropriate decision/direction
• Review medical records to determine if charges and/or services are appropriate (e.g., reviewing CPT/HCPCS codes, up-coding practices, and similar items)
• Analyze level of care on in-patient reviews. Track trends in billing patterns by provider and report to leadership practices that may need further investigation
• Develop and sustain positive working relationships, collaborating with physicians, nurses, ancillary personnel and all others as appropriate to promote open communication channels, obtain/disseminate information, and enhance customer relations
• Inform appropriate staff for coordination and negotiation of financial arrangements for non-contracted and/or fee-for-service providers and facilities
• Provide reports as necessary
• Adapt to changes or unusual circumstances to promote cooperation and minimize disruption of working environment
• Perform any other duties as required to ensure Health Plan operations and department business needs are successful

Qualifications

Education & Experience

• A minimum of one (1) year of relevant work experience
• Recent experience with inpatient and outpatient utilization and case management requiredil
• Experience in auditing claims
  • Experience in reviewing inpatient medical records and claims preferred
  • Experience in managed care, MediCal, Medicare preferred
• High school diploma or GED
  • Associate’s degree in health care or a related field from an accredited institution
• Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required

Key Qualifications

• Knowledge and understanding of:
  • CPT, ICD-10, HCPCS and hospital revenue codes
  • Nationally recognized clinical criteria (e.g., InterQual, Milliman, Apollo)
  • Medi-Cal, Medicare and other state/federal Program & Regulations
  • Foundations of nursing practice and clinical pathways across inpatient, outpatient, and post‑acute settings
  • Health plan policies, prior authorization protocols, appeals processes, and denial management
  • Proficient in computer applications such as Word and Excel
  • Skilled in Data Entry
  • Skilled clinical review and judgement
  • Data analysis and trend identification skills
  • Communication skills (both written and verbal)
• Proven ability to:
  • Exercise sound clinical judgement with minimal supervision
  • Escalate appropriately to Medical Director for complex determinations
  • Build trust and collaboration with physicians, nurses, ancillary staff, and claims personnel
  • Navigates diverse perspectives
  • Adjust to policy updates, workflow changes, and unusual circumstances while maintaining service quality
  • Handle PHI with strict adherence to privacy and security standards; maintains ethical audit practices
  • Possess a strong attention to detail with the ability to multi-task

Work Model Location

Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership)

Pay Range

USD $63,897.60 - USD $83,075.20 /Yr.