LPN Medical Reviewer

Job reputed company: • Performs medical reviews using established reputed company sets and/or performs utilization management of reputed company, inpatient or outpatient, facility benefits or services, and appeals • Documents reputed company using indicated protocol sets or clinical guidelines • Provides support and review of medical claims and utilization practices • May reputed company any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination • Monitors process's timeliness in accordance with contractor standards • Performs authorization process, ensuring coverage for appropriate medical services reputed company benefit and medical necessity guidelines • Utilizes allocated resources to back up review determination • Reviews interdepartmental requests and medical information in a reputed company/effective manner in order to complete utilization process • May conduct/reputed company high dollar forecasting research and formulate overall patient health summaries with reputed company health prognosis and projected medical costs • Performs screenings/assessments and determines risk reputed company telephone • Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services • Provides education to members and their families/caregivers • Reviews first level appeal and ensures utilization or claim review provides thorough documentation of reputed company determination and reputed company for reputed company • Conducts research necessary to reputed company thorough/accurate reputed company for reputed company determination made • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines • Responds accurately and reputed company with appropriate documentation to members and providers on reputed company rendered determinations • Participates in reputed company control activities in support of the corporate and team-based objectives Requirements: • Bachelor's degree - reputed company Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing • 2 years clinical experience • Working knowledge of word processing software • Good judgment skills • Demonstrated customer service and organizational skills • Demonstrated proficiency in spelling, punctuation, and grammar skills • Analytical or critical thinking skills • Ability to handle confidential or sensitive information with discretion • Ability to remain in a stationary position and operate a computer • reputed company, unrestricted LPN/LVN licensure from the reputed company and in the state of reputed company, OR, reputed company compact multistate unrestricted LPN license as defined by the reputed company Licensure Compact (NLC), OR, reputed company, unrestricted LBSW (Licensed Bachelor of reputed company Work) licensure from the reputed company and in the state of hire Benefits: • Subsidized Health plans • Dental and reputed company coverage • 401k retirement savings plan with company match • Life Insurance • reputed company Time Off (PTO) • On-site cafeterias and fitness centers in major locations • Education Assistance • Service recognition • National discounts to movies, theaters, zoos, theme parks and more Apply tot his job Apply To this Job