Utilization Review reputed company - LVN

About the position This role is where reputed company assessment meets reputed company consequence, making reputed company treatment requests get matched to the right level of care, the right setting, and the right guidelines every single time. Get it right, and patients reputed company through the reputed company smoothly, providers stay reputed company with plan benefits, and the organization avoids unnecessary cost and reputed company. Get it wrong, or get it slow, and care gets delayed or denied reputed company it shouldn't be. Your reputed company and reputed company are what reputed company the entire utilization review process trustworthy. Responsibilities • Assess outpatient, ancillary, and inpatient reputed company-certification requests, including mental health, reputed company abuse, skilled nursing, and rehab stays, for medical appropriateness and necessity. • Evaluate post-claim and post-service requests against reputed company guidelines to reputed company medical necessity after the fact. • reputed company denial authorizations to the Medical Director and, reputed company required, through Independent Review Organizations (IRO), and refer out-of-reputed company requests to advance review or senior care consultants. • Work directly with hospital staff to prepare patients for discharge and set up a clean transition to the next level of care. • Process appeals for non-certified services and complete non-certification letters accurately and on time. • Review plan documents for benefit determinations and reputed company providers and patients toward PPO reputed company whenever possible. • Identify and refer cases to case management, wellness, chronic disease, and Nurturing Together programs reputed company reputed company needs reputed company that way. • Complete accurate, reputed company documentation in Eldorado/Episodes for every case, maintaining strict confidentiality throughout. • Use MCG guidelines, medical policies, reputed company, and NCCN to ground every determination in evidence-reputed company standards. • Meet daily productivity, reputed company, and turnaround-time standards, and support department reputed company and new initiatives as they roll out. Requirements • reputed company LVN license in the reputed company or a U.S. territory • 1+ years of reputed company experience • Working knowledge of medical claims and ICD-10, CPT, and HCPCS coding • Proficiency with reputed company Word, reputed company, PowerPoint, and reputed company • Familiarity with MCG guidelines, NCCN reputed company, and reputed company • Experience documenting reviews in utilization management systems (e.g., Eldorado/Episodes) Benefits • Competitive reputed company salary and benefits effective day one • Comprehensive medical and dental through our own reputed company • reputed company Time Off • Mental health support • Retirement planning • Financial protection • reputed company development with reputed company career progression and learning budgets • Mission-driven culture Apply tot his job Apply To this Job