Claims Review Nurse, LVN (Remote)

Claims Review Nurse, LVNFind 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.The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.PerksIEHP 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 salaryState of the art fitness center on-siteMedical Insurance with Dental and VisionLife, short-term, and long-term disability optionsCareer advancement opportunities and professional developmentWellness programs that promote a healthy work-life balanceFlexible Spending Account – Health Care/ChildcareCalPERS retirement457(b) option with a contribution matchPaid life insurance for employeesPet care insuranceKey Responsibilities:Audit medical necessity claims in accordance with departmental policies and proceduresAct as the key clinical interface between the Claims and Medical Services departmentsAttend UM and Claims team meetingsReview inpatient and outpatient claims that require authorization, appeals and other disputed claims in a timely manner to meet regulatory requirementsObtain the appropriate clinical information necessary to make authorization decisions for unauthorized claimsIdentify potential denied services/admissions/days and present to the Medical Director, both Plan and Direct, for appropriate decision/directionReview 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 investigationDevelop 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 relationsInform appropriate staff for coordination and negotiation of financial arrangements for non-contracted and/or fee-for-service providers and facilitiesProvide reports as necessaryAdapt to changes or unusual circumstances to promote cooperation and minimize disruption of working environmentPerform any other duties as required to ensure Health Plan operations and department business needs are successfulQualifications:Education & ExperienceA minimum of one (1) year of relevant work experienceRecent experience with inpatient and outpatient utilization and case management requiredExperience in auditing claimsExperience in reviewing inpatient medical records and claims preferredExperience in managed care, MediCal, Medicare preferredHigh school diploma or GEDAssociate's degree in health care or a related field from an accredited institutionPossession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians requiredKey QualificationsKnowledge and understanding of:CPT, ICD-10, HCPCS and hospital revenue codesNationally recognized clinical criteria (e.g., InterQual, Milliman, Apollo)Medi-Cal, Medicare and other state/federal Program & RegulationsFoundations of nursing practice and clinical pathways across inpatient, outpatient, and post-acute settingsHealth plan policies, prior authorization protocols, appeals processes, and denial managementProficient in computer applications such as Word and ExcelSkilled in Data EntrySkilled clinical review and judgementData analysis and trend identification skillsCommunication skills (both written and verbal)Proven ability to:Exercise sound clinical judgement with minimal supervisionEscalate appropriately to Medical Director for complex determinationsBuild trust and collaboration with physicians, nurses, ancillary staff, and claims personnelNavigates diverse perspectivesAdjust to policy updates, workflow changes, and unusual circumstances while maintaining service qualityHandle PHI with strict adherence to privacy and security standards; maintains ethical audit practicesPossess a strong attention to detail with the ability to multi-taskStart your journey towards a thriving future with IEHP and apply TODAY!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.