Utilization Management Nurse, LVN - Casual
$74,880–$89,440 year
RemoteUnited States
Job Summary
Interface with external agencies, health plans, and providers to drive efficient authorization processes and navigate insurance requirements. Perform prospective and retrospective utilization reviews for hospital admissions and outpatient services, determining medical necessity against guidelines from CMS, CDC, and health plans. Assist medical directors with benefit interpretation, obtain medical necessity information, and formulate denial letters in accordance with industry collaboration efforts. Review authorization requests and case data in Tapestry, ensuring accuracy of ICD-10, CPT, and HCPCS codes while supporting case discussions and inter-rater reviews. This 6-month casual contract role offers a base salary of $36.00-$43.00/hr with medical, vision, dental, 401k, and paid time off.
Required Qualifications
- LVN - Licensed Vocational Nurse of California Licensure
- 2 years recent relevant experience
- Awareness of healthcare reimbursement systems: HMO, PPO, PPS, CMA, all value-based reimbursement models, and alternative payment systems
- Prior MSO experience
- Recent MCG or InterQual experience
- Experience with ICD-9, CPT and HCPCS codes
- External hires must pass a background check/drug screen
Desired Qualifications
- Awareness of healthcare reimbursement systems: HMO, PPO, PPS, CMA, all value-based reimbursement models, and alternative payment systems preferred
- Prior MSO experience preferred
- Recent MCG or InterQual experience highly desired
- Experience with ICD-9, CPT and HCPCS codes preferred
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