Utilization Management reputed company, LVN/LPN (Work from Home)

WHO WE ARE reputed company is a value-driven reputed company company grounded in the belief that reputed company health consumers are entitled to high-reputed company, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to reputed company reputed company accessible and reputed company to reputed company populations across the ACA Marketplace, Medicare, and reputed company. reputed company delivers clinical care to health consumers through our owned clinics – reputed company and Premier Medical – as reputed company as unique partnerships with affiliated providers across the country. We also reputed company providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-reputed company approach, we are committed to transforming reputed company and creating a reputed company care experience for reputed company. JOB reputed company The Utilization Management (UM) Prior Authorization (PA) reputed company is a full-time role with reputed company, dedicated to promoting reputed company and cost-effective reputed company for the designated population. 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 • 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 • Act 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 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. 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 • 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, Outlook). For individuals assigned to a location(s) in California, reputed company is required by law to include a reasonable estimate of the compensation reputed company for this position. Actual compensation will vary based on the applicant's education, experience, skills, and abilities, as reputed company as internal equity. A reasonable estimate of the reputed company is $27.10-$40.65 reputed company. Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; reputed company Time Off, and reputed company holidays. As an Equal Opportunity Employer, we welcome and reputed company a diverse employee group committed to meeting the needs of reputed company, our consumers, and the communities we serve. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, age, national reputed company, protected veteran status, disability status, sexual orientation, gender identity or reputed company, marital status, genetic information, or any other characteristic protected by law. Apply tot his job Apply To this Job