LVN - Quality Assurance/Utilization Review - Business Development - Full Time 8hr

cvhp; Covina (CA); On-site; USD 43,000 - 64,000; Full time

Job summary

Emanate Health in Covina, CA is seeking an experienced Utilization Review Nurse to evaluate medical records and determine medical necessity under applicable policies and guidelines. The role requires clinical judgment and documentation of decisions using protocol sets and guidelines.

The position demands a minimum of three years in utilization management, excellent customer service, and a current California LVN license. Pay range is $31.03–$46.54 per hour.

Qualifications

• Minimum of three years of utilization management experience.
• Experience in quality-related roles preferred.
• Current California LVN license.
• Excellent customer service skills required.

Responsibilities

• Evaluate medical records to determine medical necessity using clinical guidelines and policy.
• Document decisions using indicated protocol sets or clinical guidelines.
• Provide support and review of medical claims and utilization practices; refer to Medical Directors when needed.

Skills

Utilization management

Customer service

Computer proficiency

Job description

Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals.

On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country.

Job Summary

The Utilization Review Nurse will evaluate medical records to determine medical necessity by applying clinical acumen and the appropriate application of policies and guidelines to urgent and standard reviews. You will document decisions using indicated protocol sets, or clinical guidelines and provide support and review of medical claims and utilization practices. Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings.

Job Requirements

Minimum Experience Requirement:

Minimum of three years of utilization management experience. Experience in quality- related job preferred. Computer proficiency is required. Excellent customer service skills required.

Minimum License Requirement:

Current California LVN license.

Delivering world-class health care one patient at a time.

Pay Range:

$31.03 - $46.54