Claims Review Nurse, LVN

Job not on LinkedIn

🔥 2 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $63.9k - $83.1k / year

⏰ Full Time

🟢 Junior

👻 Ghost score 2%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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IEHP

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1995

🛡️ Insurance

💼 Consulting

📦 Logistics

💰 Grant on 2021-02

Insurance • Consulting • Logistics

IEHP is a health plan dedicated to serving low-income individuals and families in Riverside and San Bernardino counties. They offer a variety of programs including Medi-Cal, DualChoice, and Covered California, providing healthcare coverage for residents who may not otherwise have access to necessary medical services. With a focus on holistic health and community wellness, IEHP partners with local doctors and facilities to ensure comprehensive care for their members, supporting them with resources in mental health, fitness classes, and wellness education.

📋 Description

• Conduct timely medical reviews of IEHP facility and professional claims and appeals • Identify process improvements in the UM/Claims interface • Make recommendations to improve the claim authorization process and business rules between Claims and UM teams • Exercise independent judgment in conducting claims reviews • Support key clinical determinations in alignment with guidance from the Supervisor, Integrated Transitional Care • Report to the Supervisor, Integrated Transitional Care • Incorporate IEHP’s Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation

🎯 Requirements

• A minimum of one (1) year of relevant work experience • Recent experience with inpatient and outpatient utilization and case management required • Experience in auditing claims • Experience in reviewing inpatient medical records and claims preferred • Experience in managed care, MediCal, Medicare preferred • High school diploma or GED • Associate’s degree in health care or a related field from an accredited institution • Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required • Knowledge and understanding of CPT, ICD-10, HCPCS and hospital revenue codes • Knowledge of nationally recognized clinical criteria (e.g., InterQual, Milliman, Apollo) • Knowledge of Medi-Cal, Medicare and other state/federal Program & Regulations • Knowledge of foundations of nursing practice and clinical pathways across inpatient, outpatient, and post-acute settings • Knowledge of health plan policies, prior authorization protocols, appeals processes, and denial management • Proficient in computer applications such as Word and Excel • Skilled in Data Entry • Skilled clinical review and judgement • Data analysis and trend identification skills • Communication skills (both written and verbal) • Ability to exercise sound clinical judgement with minimal supervision • Ability to escalate appropriately to Medical Director for complex determinations • Ability to build trust and collaboration with physicians, nurses, ancillary staff, and claims personnel • Ability to navigate diverse perspectives • Ability to adjust to policy updates, workflow changes, and unusual circumstances while maintaining service quality • Ability to handle PHI with strict adherence to privacy and security standards and maintain ethical audit practices • Strong attention to detail with the ability to multi-task

🏖️ Benefits

• Competitive salary • State of the art fitness center on-site • Medical Insurance with Dental and Vision • Life, short-term, and long-term disability options • Career advancement opportunities and professional development • Wellness programs that promote a healthy work-life balance • Flexible Spending Account – Health Care/Childcare • CalPERS retirement • 457(b) option with a contribution match • Paid life insurance for employees • Pet care insurance