Medical Reviewer LPN

Health Care Service Corporation; Albuquerque (NM); Remote; USD 45,000 - 101,000; Full time

Job summary

Join a purpose-driven company that values employee growth and offers a rewarding career in healthcare. This remote role involves conducting pre-authorization reviews and collaborating with healthcare providers to ensure quality care for members. You'll be part of a dynamic team that promotes effective resource use and evaluates medical necessity across various services. With comprehensive benefits and a focus on professional development, this opportunity is perfect for those looking to make a meaningful impact in the healthcare industry.

Benefits

Health and wellness benefits

401(k) plan

Pension plan

Paid time off

Parental leave

Disability insurance

Life insurance

Employee assistance program

Paid holidays

Tuition reimbursement

Qualifications

• Minimum 3 years of clinical experience in healthcare settings.
• Strong communication and customer service skills are essential.

Responsibilities

• Conduct pre-authorization reviews in line with medical criteria.
• Collaborate with healthcare providers to optimize member benefits.

Skills

Clinical experience

Customer service orientation

Verbal communication skills

Written communication skills

Interpersonal skills

Familiarity with PC or database systems

Education

Valid LPN license

Tools

Medical coding knowledge (CPT/HCPCS/ICD-10)

Job description

At HCSC, our employees are the cornerstone of our business and the foundation of our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

Join HCSC and be part of a purpose-driven company that will invest in your professional development.

Job Summary

This position is responsible for pre-authorization reviews in accordance with the medical contract, regulations, medical criteria, utilization review, and quality of care. The role involves collaborating with healthcare providers, members, and business partners to optimize member benefits, evaluate medical necessity, and promote effective resource use. Medical necessity reviews may include inpatient admissions, outpatient services, surgical and diagnostic procedures, home health, durable medical equipment, and out-of-network services.

Job Requirements

• LPN with a valid, current, unrestricted clinical license in the state of operations.
• At least 3 years of clinical experience in a physician's office, hospital, or surgical setting.
• Customer service orientation to assist internal and external customers.
• Strong verbal and written communication skills.
• Interpersonal skills and the ability to be a team player.
• Willingness and ability to travel.
• Familiarity with PC or database systems.
• Incumbents with nursing licenses required to obtain and maintain additional multi-state licenses as per management's requirements; fees covered by HCSC. Non-nursing clinical licenses do not require multi-state licensing.

Preferred Job Requirements

• Multi-state License for LPN / LVN (Preferred)
• Utilization review or management experience
• Strong organizational, planning, and communication skills
• Knowledge of insurance industry, medical coding (CPT/HCPCS/ICD-10)
• Knowledge of National and Local Coverage Determinations and MCG criteria is a plus.

Work Schedule: Weekend and Holiday rotation (2 holidays per year)

This is a remote role: Must reside within 250 miles of the office or within the posted state.

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Referral and Benefits

If referred by a connection at HCSC, inquire about our Employee Referral process.

Pay Transparency: We offer comprehensive benefits including health and wellness, 401(k), pension, paid time off, parental leave, disability insurance, life insurance, employee assistance, paid holidays, tuition reimbursement, and more. Details at https://careers.hcsc.com/totalrewards.

Compensation varies based on skills, education, and experience, with an annual incentive bonus plan applicable.

HCSC Employment Statement

We are committed to diversity and equal opportunity employment. All qualified applicants will be considered regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristics.

Base Pay Range: $45,000.00 - $100,100.00