Claims Review Nurse, LVN (Remote)

IEHP; Rancho Cucamonga (CA); On-site; USD 64,000 - 83,000; Full time

Benefits offered by this job

Competitive salary

State of the art fitness center on‑sit

Medical Insurance with Dental and Vis

Job summary

IEHP is seeking a Claims Review Nurse, LVN to perform timely medical reviews of facility and professional claims and appeals, exercising independent judgment and supporting clinical determinations under supervision. The role supports UM/Claims interfaces and helps optimize claim authorization and business rules between teams.

Qualifications include active CA LVN license, 1 year of relevant experience, familiarity with Medi-Cal/Medicare, and knowledge of CPT/ICD-10/HCPCS.

Qualifications

• Minimum 1 year of relevant work experience
• Recent inpatient and outpatient utilization and case management experience required
• Experience in auditing claims; inpatient records review preferred; managed care/Medi-Cal/Medicare preferred
• Active, unrestricted LVN license in CA

Skills

CPT/ICD-10/HCPCS knowledge

Clinical criteria knowledge

Medi-Cal/Medicare familiarity

Nursing judgement

Data entry

Data analysis

Communication skills

Education

LVN license (CA)

Associate degree in health care

High school diploma or GED

Tools

Word

Excel

Job description

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.

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.

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

Education & Experience

• A minimum of one (1) year of relevant work experience
• Recent experience with inpatient and outpatient utilization and case management required
• 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

Start your journey towards a thriving future with IEHP

Pay Range

• $63,897.60 USD Annually - $83,075.20 USD Annually