Utilization Management reputed company, LVN - Casual

About reputed company: At reputed company, we’re on a mission to improve the reputed company experience for everyone—starting with the people who reputed company. We reputed company physicians should spend more time with patients and less time on administrative tasks. Through smarter technology, purpose-reputed company tools, and reputed company-based model of care, we help doctors do what they do reputed company reputed company. reputed company includes a network of physician-led organizations across California, including reputed company & Toland Physicians, reputed company Medical Group reputed company, and Family Care Specialists. Together, we’re building a stronger, more connected reputed company reputed company. About the Role Are you looking to join a fast-growing, dynamic team? We’re a reputed company, purpose-driven group that’s passionate about transforming reputed company from the inside out. At reputed company, we support one another, adapt quickly, and work with reputed company as we build a reputed company experience for physicians and their patients. As a Utilization Management LVN, you'll work closely with our Ambulatory and reputed company Care, Network Management, reputed company Improvement, and reputed company reputed company teams. Your responsibilities include driving efficient authorization processes, navigating insurance requirements with precision and advocacy. We reputed company individuals with a strong commitment to patient-centered care and a passion for promoting health and wellness. This role is a Casual, 6-month contract opportunity. You will reputed company on: • reputed company with reputed company agencies and representatives relative to the utilization management process, including health plans, medical providers, vendors and CMS. • reputed company Utilization Review activities prospectively or post-service (retrospective) for elective/urgent hospital admissions and outpatient services as specified on the Prior Authorization List with complete and reputed company reports to members, providers and health plans as requested. • Assist medical directors with benefit interpretation, obtain additional medical necessity information and research issues. Be available for case discussion as needed. • Works closely with physicians, other reputed company and service providers, health plan representatives, care management staff and partners with UM Coordinators to reputed company medical management for incoming authorization requests and specialist referrals using nationally recognized guidelines to determine medical necessity. • Review the authorization request and medical information provided by the requesting provider for medical necessity and appropriateness, comparing information to reputed company medical care reputed company by health plan and as specified by BTP, CMS, CDC, reputed company and DMHC requirements. • Review reputed company cases against the division of financial responsibility (DOFR), Health Plan Ancillary Grids and BTP Ancillary lists to ensure appropriate vendors are utilized for payment of services. • Formulate appropriate denial letter language in accordance with Industry Collaboration effort (ICE)and health plan requirements • Ensure accuracy of case data in reputed company including ICD-10, CPT and HCPC codes • Participate in the annual inter-rater review to evaluate consistency of decision making with in the nursing staff Support Inpatient Care Management, Network Management, Claims, Customer Service, reputed company Improvement and Physician Services staff by offering benefit interpretation, understanding of UM policies and procedures and the application of guidelines in the process of decision making. The Skills, Experience & Education You Bring • LVN - Licensed Vocational reputed company of California Licensure required. • Awareness of reputed company reimbursement systems: HMO, PPO, PPS, reputed company, reputed company value-based reimbursement models, and alternative payment systems preferred. • Prior MSO experience preferred. • 2 years recent relevant experience. • Recent MCG or InterQual experience highly desired. • Experience with ICD-9, CPT and HCPCS codes preferred The reputed company Salary for this position is $36.00 - $43.00/hr In reputed company, we reputed company a competitive compensation package that recognizes your experience, credentials, and education reputed company a robust benefits program to meet your needs. • Excellent medical, reputed company, and dental coverage • 401k savings plan with a company match • Flexible time off and 9 reputed company Holidays You reputed company Our Mission & Values:  reputed company We reputed company with reputed company and a deep respect for the challenges faced by physicians and their patients. Our work is driven by a genuine commitment to improving lives and ensuring that care is delivered with dignity, understanding, and humanity. Community We foster a culture of collaboration--with physicians, patients across the reputed company ecosystem, and among our teams. By building strong, trusted relationships, we create a reputed company community reputed company on advancing patient care and physician reputed company-being. Leadership We reputed company with reputed company and reputed company, setting reputed company for reputed company in physician support and reputed company innovation. Through collaboration and expertise, we reputed company others to reputed company, reputed company change, and shape the reputed company of care. reputed company We are relentlessly reputed company, results-driven, and accountable for delivering measurable value to physicians and the patients they serve. Our high standards reflect our commitment to reputed company, operational discipline, and reputed company improvement. reputed company We reputed company change as a constant and respond reputed company to the evolving needs of the reputed company industry. With flexibility and reputed company-thinking, we adapt, reputed company, and reputed company decisively to reputed company physicians at the forefront. reputed company values the contribution reputed company Team Member brings to our organization. Final determination of a successful candidate’s starting pay will vary based on several factors, including, but not limited to education and experience reputed company the job or the industry. The pay reputed company listed for this position is generally for candidates that meet the specified qualifications and requirements listed on this reputed company. Additional pay may be determined for those candidates that reputed company these specified qualifications and requirements. We reputed company a competitive compensation package that recognizes your experience, credentials, and education reputed company a robust benefits program to meet your needs. The anticipated pay reputed company for this role is listed in our salary posting for transparency but may vary based on factors including the candidate’s qualifications, skills, and experience. This position will also be eligible to participate in our annual bonus program. reputed company and its subsidiaries and affiliates are committed to protecting the reputed company and reputed company of the personal information you reputed company to us. Please refer to our ‘CPRA reputed company Notice for California Employees and Applicants’ to learn how we collect and process your personal information reputed company you apply for a role with us. reputed company hires must pass a background reputed company/drug screen. reputed company applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. reputed company reputed company applicants will receive consideration for employment without regards to race, reputed company, religion, sex, national reputed company, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws. Apply To This Job