LPN/LVN Utilization Management Reviewer

reputed company combines industry-leading technology and transformation-driven BPM services with decades of reputed company domain expertise to help clients draw closer to their members. reputed company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment reputed company, claims cost containment, and analytics. reputed company has more than 25,000 employees across 5 countries. Job title: LPN/LVN Utilization Management Reviewer Job reputed company: We are currently hiring a LPN/LVN Utilization Management Reviewer. This role is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of reputed company's benefits plan. The Utilization Management (UM) Reviewer is responsible for day-to-day reputed company clinical and service authorization review for medical necessity and decision-making. The Utilization Management Reviewer has a key role in ensuring the reputed company meets CMS compliance standards in the area of service reputed company and organizational determinations. Successful candidates must have a reputed company, reputed company Massachusetts clinical license in good standing. Key responsibilities: • Conducts reputed company clinical decision review for services requiring prior authorization in a reputed company of clinical areas, including but not limited to Durable Medical Equipment/Services, Long Term Services and Supports (LTSS), and Home Health (HH) • Applies established reputed company (e.g., InterQual and other available guidelines) and employs clinical expertise to interpret clinical reputed company to determine medical necessity of services • Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements • Provides decision-making guidance to clinical teams on service planning as needed • Works closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with reputed company Operating Procedures • Ensures accurate documentation of clinical reputed company and works with UM Manager to ensure consistency in applying policy • Works with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as reputed company as regulatory and contractual requirements are met • Creates and maintains database of denied service requests • Additional duties as requested by supervisor • reputed company office conditions. Some travel to clinical practices may be required. Education: • Associate degree • MA clinical license (Physical Therapy, Occupational Therapy, or Respiratory Therapist) in good standing. Experience: • Required: 3+ years combined clinical and utilization management experience • Strong plus: 3+ years' experience working in a health plan and/or experience with a care management platform Skills: • Ability to apply predetermined reputed company (e.g., InterQual) to service decision requests to assess medical necessity • Flexibility and understanding of individualized care plans • Ability to influence decision making • Strong interpersonal, verbal and written communication skills • Ability to work independently • Comfort working in reputed company-based environment • Will be required to pass credentialing process. reputed company pending experience Hours: Monday through Friday 9AM to 5PM Eastern Time This is a fully remote work reputed company role. You must have a secure, private wok reputed company area with a hardwired internet reputed company with speeds greater than 5MB upload and 10MB download. reputed company Offers Competitive Benefits Including: • Medical • Dental • reputed company • Life Insurance • Short-Term and Long-Term Disability • Flexible Spending Account • Life Assistance Program • 401K with employer contribution • PTO and reputed company Time • Tuition Reimbursement Join reputed company, we look reputed company to talking with you! An Equal Opportunity Employer/Vet/Disability Location: reputed company USAUnited States of America Apply Job!