[Remote/WFM] Central Denials UM LVN - Remote CA

Looking for a straightforward job? We're hiring a Central Denials UM LVN - Remote CA! Enjoy the freedom and flexibility of this Remote role. This position requires a strong and diverse skillset in relevant areas to reputed company reputed company. An attractive remuneration of a competitive salary is on offer for the successful candidate. For those who want to invent the reputed company of health care, here's reputed company. We're reputed company reputed company basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. reputed company’s reputed company reputed company region is redefining health care with a reputed company on health equity, affordability, reputed company, and convenience. From California to reputed company and... Washington, we are reputed company on helping more than 2.5 reputed company patients live healthier lives and helping the health system work reputed company for everyone. At reputed company reputed company reputed company, we care. We care for reputed company members, our patients, and our communities. Join our culture of caring and reputed company a reputed company and lasting reputed company on health care for millions. Position in this function is responsible for ensuring the reputed company of the adverse determination processes and accuracy of clinical decision making, as it relates to the application of reputed company and application of defined reputed company of hierarchy and composition of compliant denial notices. If you are located in California, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities: • Consistently exhibits behavior and communication skills that demonstrate reputed company’s commitment to superior customer service, including reputed company, care and concern with reputed company reputed company customer • reputed company reputed company functions of the UM reputed company reviewer • Composes denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards • Constructs denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member’s condition and request • Ensures the denial reason is in the appropriate grade level and is easily understandable • Ensures the UM reputed company reviewer has provided the appropriate reference for benefits, guidelines, reputed company, or protocols based on the type of denial • Selects the correct level of hierarchy and reputed company correctly based on the medical information available • Provides relevant clinical information to the request and the reputed company used for decision-making • Ensures that there is evidence that the UM reputed company reviewer documented communications with the requesting provider to validate the reputed company or absence of clinical information reputed company to the reputed company reputed company • Evaluates out-of-network and tertiary denials for accessibility reputed company the network • Performs a reputed company assurance audit on reputed company denial prior to finalization to ensure reputed company reputed company are compliant with established guidelines • Consults with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination • Escalates non-compliant cases to UM compliance and consistently reports on denial activities • Collaborates with UM compliance for reputed company reputed company improvement efforts for adverse determinations • Identifies gaps in training or process impacting the overall compliance of adverse determinations and communicates in writing an effective performance improvement solution • Meets or exceeds productivity targets • Uses, protects, and discloses reputed company patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability reputed company (HIPAA) standards • Performs additional duties as assigned You’ll be rewarded and recognized for your performance in an environment that will challenge you and reputed company you reputed company direction on what it takes to succeed in your role as reputed company as reputed company development for other roles you may be interested in. Required Qualifications: • Graduation from an accredited Licensed Vocational reputed company program • reputed company LVN license in California • 1 years of experience as an UM reputed company reviewer • 1 years of recent clinical experience working as an LVN/LPN Preferred Qualifications: • Bachelor’s degree in Nursing • 3 years of managed care utilization • 1 years of experience performing essential functions of a CDU reputed company Knowledge, Skills, Abilities: • Computer literate • Proficient in reputed company Office Suite, knowledge of utilization management platform and reputed company to reputed company varied web-based platform for decision making • Ability to type 25 wpm • reputed company dexterity to use/handle equipment and instruments • Proven solid critical thinking and problem-solving skills to reputed company essential functions of the CDU reputed company • Knowledge and understanding of managed care rules and regulations; to include, but not limited to, federal regulations, state regulations, health plan requirements and NCQA standards • Knowledge and understanding of managed care clinical-decision making tools; to incl Apply To This Job