Utilization Review Specialist – LPN Required

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

📋 Description

• Facilitate training sessions for newly appointed onshore Representatives and supervise the creation of payer-specific training resources.

• Implement CDI and standardization training for documentation across various clients.

• Collaborate with QA to conduct ongoing audits of utilization reviews and track accuracy trends.

• Offer educational insights to facilities regarding the documentation needed for authorization approvals.

• Aid in the transfer of knowledge to Training Leads and share updates on new payers/processes.

• Perform administrative, concurrent utilization, and retrospective reviews through live interactions, voicemail, fax, and portal evaluations.

• Organize peer reviews as necessary.

• Provide templates for the Assignment of Responsibility form upon admission when necessary.

• Input utilization review authorization details into facility EMR billing systems and internal workflow systems.

• Follow up on outstanding authorizations to obtain approvals and required documentation.

• Record and monitor utilization review activities in Salesforce and other designated systems.

• Assist in retrieving documents from EMRs.

• Act as a liaison between facilities and internal teams.

• Dispatch morning and end-of-day facility status updates along with weekly summaries for stakeholders.

• Maintain knowledge of levels of care, insurance authorization prerequisites, and behavioral health regulations.

• Identify documentation deficiencies impacting authorization approvals.

• Review clinical documentation from a licensed nursing perspective and communicate any charting deficiencies to facilities.

• Serve as a clinical resource for escalated issues and complex case evaluations.

• Ensure that authorization requests are in line with policies and payer requirements.

• Undertake additional utilization review and prior authorization responsibilities as needed.

⛳️ Requirements

• Current and unrestricted Licensed Practical Nurse (LPN) license.

• At least 2 years of experience in Behavioral Health Clinical, Utilization Review, case management, or prior authorization is preferred.

• Familiarity with insurance authorization processes, levels of care, and medical necessity standards.

• Exceptional verbal and written communication skills for interactions with facilities.

• Strong organizational abilities, high accuracy, and excellent follow-up and documentation skills.

• Proficiency in EMR systems, Salesforce, and other workflow management platforms.

• Capability to prioritize tasks and handle multiple authorization cases at once.

🏝️ Benefits

• Comprehensive health, dental, and vision insurance.

• Retirement savings plan with employer matching.

• Opportunities for professional development and continuing education.

• Flexible work environment and remote work options.