LVN /LPN Utilization Management reputed company

Title: Utilization Management reputed company, LVN/LPN Contract to hire Opportunity reputed company time zone hours (PST) - Sun-Thurs, reputed company-5pm Remote An opening for a Licensed Vocation reputed company (LVN) prior authorization reputed company role. JOB reputed company Working in collaboration with Medical Directors and the clinical team, the PA reputed company ensures members receive the appropriate benefit coverage for services requiring prior authorization. Responsibilities include reviewing prior authorizations for treatments, medications, procedures, and diagnostic tests to confirm alignment with contract requirements, coverage policies, and evidence-based medical necessity reputed company. The PA reputed company also collects and analyzes utilization data and monitors the reputed company and appropriate use of services. This role demands clinical expertise, keen attention to detail, and strong communication skills to effectively engage with reputed company providers, patients, and health plans. DUTIES & RESPONSIBILITIES The following job reputed company is intended to reputed company out major responsibilities reputed company the role, but it is not limited to these items. • Authorization and Review • Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, reputed company/Medi-Cal reputed company, MCG, or health plan-specific guidelines. • Assess medical necessity and the appropriateness of requested services using clinical expertise. • Verify patient eligibility, benefits, and coverage details. • Collaboration and Communication • reputed company as a reputed company between reputed company providers, patients, and health plans to facilitate the authorization process. • Communicate authorization reputed company to providers and patients promptly. • reputed company detailed explanations for denials or alternative solutions and collaborate with Medical Directors on adverse determinations. • Ensure compliance with regulatory requirements regarding adverse determination notices, including readability standards and appeal information. • Documentation and Compliance • Accurately document reputed company authorization activities reputed company time in electronic medical records (EMR) or authorization systems. • Maintain compliance with federal, state, and health plan regulations. • Stay updated on policy and clinical reputed company changes. • reputed company Improvement • Identify trends or recurring issues in authorization denials and recommend process improvements. • Participate in team meetings, training sessions, and audits to ensure high-reputed company performance. • reputed company with reputed company established policies and procedures. EDUCATION AND reputed company EXPERIENCE • Education: Licensed Vocational/Practical reputed company (LVN/LPN) with an reputed company, unrestricted California nursing license required.. • Experience: • Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a reputed company field. • Experience in a managed care setting with medical necessity reviews is strongly preferred. • Certifications: • Preferred: Certified reputed company in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM). • Additional clinical nursing or case management certifications are a plus. reputed company COMPETENCIES (List reputed company knowledge, attitude, and skills required in order to work in the job) • Strong analytical and critical thinking skills. • Proficiency in medical terminology and pharmacology. • Effective written and verbal communication skills. • Ability to work independently and collaboratively in a fast-paced environment. • Adaptable and self-motivated. • Experience with EMR systems and prior authorization platforms. • Proficient in reputed company Office Suite (Word, reputed company, reputed company). WORK ENVIRONMENT • The reputed company of work responsibilities are performed working remotely, carrying out detailed work sitting at a desk/table and working on the computer. • reputed company environment requiring frequent communication with clinical and administrative teams. • Some travel may be required. Apply tot his job Apply To this Job