Remote LVN Claims Reviewer: Care & Compliance

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

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.