Claims Review Nurse, LVN

This is a fully remote position, open to applicants in California.

📋 Description

• Perform timely medical evaluations of IEHP facility and professional claims and appeals.

• Identify areas for process enhancement within the UM/Claims interaction.

• Suggest improvements to the claim authorization process and business regulations between the Claims and UM teams.

• Utilize independent judgment in executing claims assessments.

• Assist with pivotal clinical decisions in accordance with guidance from the Supervisor, Integrated Transitional Care.

• Report directly to the Supervisor, Integrated Transitional Care.

• Integrate IEHP’s Quality Program objectives, including HEDIS, CAHPS, and NCQA Accreditation.

⛳️ Requirements

• At least one (1) year of pertinent work experience.

• Recent experience in inpatient and outpatient utilization and case management is mandatory.

• Experience in auditing claims is required.

• Preferred experience in examining inpatient medical records and claims.

• Preferred experience in managed care, MediCal, and Medicare.

• High school diploma or GED is necessary.

• An Associate’s degree in health care or a related field from an accredited institution is required.

• Must possess an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians.

• Understanding of CPT, ICD-10, HCPCS, and hospital revenue codes is essential.

• Familiarity with nationally recognized clinical criteria (e.g., InterQual, Milliman, Apollo).

• Knowledge of Medi-Cal, Medicare, and other state/federal programs and regulations.

• Understanding of nursing practice fundamentals and clinical pathways across inpatient, outpatient, and post-acute settings.

• Knowledge of health plan policies, prior authorization procedures, appeals processes, and denial management.

• Proficient in computer applications including Word and Excel.

• Skilled in data entry.

• Competent in clinical review and judgment.

• Strong data analysis and trend identification skills.

• Effective communication skills, both written and verbal.

• Ability to exercise sound clinical judgment with minimal supervision.

• Capacity to escalate issues to the Medical Director for complex determinations as needed.

• Ability to foster trust and collaboration with physicians, nurses, ancillary staff, and claims personnel.

• Capable of navigating diverse viewpoints.

• Adaptable to policy updates, workflow modifications, and unique circumstances while ensuring service quality.

• Commitment to handling PHI with strict compliance to privacy and security standards and maintaining ethical audit practices.

• Excellent attention to detail and ability to manage multiple tasks simultaneously.

🏝️ Benefits

• Competitive salary.

• On-site state-of-the-art fitness center.

• Medical Insurance that includes Dental and Vision coverage.

• Options for life insurance, short-term, and long-term disability.

• Opportunities for career advancement and professional development.

• Wellness programs aimed at promoting a healthy work-life balance.

• Flexible Spending Account for Health Care and Childcare.

• CalPERS retirement plan.

• 457(b) option with a contribution match.

• Paid life insurance for employees.

• Pet care insurance.