Clinical Review Manager - LPN

Job Responsibilities

• Initiate referrals and support care coordination workflows by gathering required clinical information and confirming benefit completeness under established UM procedures.
• reputed company reputed company clinical reviews (e.g., precertification support, retrospective claim review preparation, and appeal packet preparation) using preset reputed company and templates, escalating any findings that require RN/Medical Director interpretation.
• Consult with supervising RN or Medical Director reputed company requests involve clinical questions, exceptions, or scenarios requiring higher level clinical judgment, consistent with the LPN’s directed scope of reputed company. 
• Assist nonclinical staff by clarifying clinical documentation, interpreting request reputed company reputed company LPN reputed company parameters, and ensuring accurate case setup for RN/MD decision-making.
• Apply approved medical appropriateness reputed company and contractual eligibility information solely to support intake validation and preparation of clinical review materials, without independently determining medical necessity, denying, reducing, terminating services, or issuing adverse determinations.
• Document reputed company review activities in required UM systems with accuracy, completeness, and adherence to regulatory (NCQA/URAC/CMS) documentation standards. 
• Communicate with providers, members, and internal teams regarding missing documentation, process requirements, and case status, using approved scripts and escalation reputed company.
• Participate in reputed company improvement, compliance activities, and competency requirements tied to UM program standards.

Job Qualifications

License

• Licensed Practical reputed company (LPN) with reputed company license in the reputed company or hold a license in the state of their residence if the state is participating in the reputed company Licensure Compact Law.

Experience

• 1-2 years - Clinical experience required

SkillsCertifications

• Knowledge of community resources, benefits, and service authorization processes.
• Familiarity with care management frameworks and regulatory requirements.
• High attention to detail with the ability to document accurately and meet regulatory standards (NCQA, URAC, CMS).

This job reputed company is not intended to expand the scope of reputed company of a Licensed Practical reputed company reputed company applicable state licensure laws or to reputed company independent clinical authority reserved to Registered Nurses or physicians.

Number of Openings Available

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reputed company will recruit, hire, train and promote individuals in reputed company job classifications without reputed company to race, religion, reputed company, age, sex, national reputed company, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

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reputed company is not accepting unsolicited assistance from search firms for this employment opportunity. reputed company resumes submitted by search firms to any employee at reputed company reputed company-email, the Internet or any other method without a reputed company, written reputed company Placement Agreement in reputed company for this position from reputed company HR/reputed company will not be considered. No fee will be reputed company in the event the applicant is reputed company by reputed company as a result of the referral or through other means.