Licensed Practical Nurse (LPN) Utilization Review Jobs

LPN Utilization Review Full-time
Molina Healthcare

Medical Review Nurse (RN or LPN)

Molina Healthcare Harbor View Business Park, AZ
$29.05 - $56.64 / hour
Job Description Job Summary Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Molina policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers. Job Duties • Facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations. Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals. • Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. • Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. • Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. • Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. • Identifies and reports quality of care issues. • Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. • Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. • Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. • Supplies criteria supporting all recommendations for denial or modification of payment decisions. • Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. • Provides training and support to clinical peers. • Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: • At least 2 years clinical nursing experience, including at least 1 year of utilization review (prospective, retrospective and concurrent clinical review), medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. Compact license is acceptable where states allow. • Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and • Healthcare Common Procedure Coding (HCPC). • Experience working within applicable state, federal, and third-party regulations. • Analytic, problem-solving, and decision-making skills. • Organizational and time-management skills. • Attention to detail. • Critical-thinking and active listening skills. • Common look proficiency. • Effective verbal and written communication skills. • Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: • Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. • Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. • Experience with Medicare guidelines To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $56.64 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
LPN Utilization Review Outpatient Full-time
Kettering Health Network

LPN Care Navigator II-UTILIZATION MGMT

Kettering Health Network Miamisburg, OH
Job Details Physician Office | Miamisburg | Full-Time | First Shift Responsibilities & Requirements The LPN Care Navigator II supports patients and their families by coordinating care, providing education, and facilitating communication across the healthcare continuum. This role ensures patients receive timely follow-up, access to resources, and guidance in managing their health, all under the direction of a registered nurse or authorized provider. Performs other duties as assigned. All job responsibilities are to be carried out in alignment with Kettering Health's mission, vision, values, and B Safe program.Graduate of an accredited Licensed Practical Nurse (LPN) program.2–3 years of clinical experience as a Licensed Practical Nurse in a healthcare setting.Current, valid, and unrestricted Licensed Practical Nurse (LPN) license issued by the Ohio Board of Nursing. Basic Life Support (BLS) certification or ability to obtain within 30 days of hire. Preferred Qualifications Experience in care coordination, case management, or chronic disease management. Certification in care coordination or chronic disease management.
LPN Utilization Review Home Health Full-time
Molina Healthcare

Facility Site Review Nurse (LVN/LPN)- Remote in CA

Molina Healthcare Long Beach, CA
$30.37 - $55 / hour
Job Description Job Summary Provides support for clinical facility site reviews. Under the supervision of leadership, uses clinical judgement within appropriate scope to independently conduct reviews and other monitoring activities for primary care providers, specialty care providers, skilled nursing facilities, sub-acute facilities, intermediate care facilities for developmentally disabled and community-based adult services sites, and other network providers. Completes reviews in alignment with local/state/federal requirements and internal Molina policies and procedures. Leverages survey review data to develop reports, document review outcomes, and identify opportunities for ongoing program improvement. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties • Conducts onsite, virtual and/or desktop reviews, including but not limited to the following: Physical Accessibility Review Survey (PARS), CR5/ member grievance reviews, Healthcare Delivery Organization (HDO)/credentialing reviews, initial health appointment medical record reviews, quality grant program reviews, and Quality Assurance Performance Improvement (QAPI) reviews. • Completes all aspects of facility site reviews using appropriate assessment tool and established regulations/policies and procedures. • Reviews and audits provider quality programs, processes, and policies. • Documents discussions and correspondence in facility site review (FSR) files as appropriate. • Documents review outcomes and other details in designated database, develops reports, and ensures proper document collection throughout the review process. • Communicates and coordinates information and findings from site visits between FSR leadership, internal and external staff and customers. • Assists with quality interventions program documentation and updates, reports, presentations, etc. • Represents as a Molina liaison to address provider questions and concerns. • Collaborates directly with providers to provide education, resources and tools to assist in achieving and maintaining compliance with local, state, and federal requirements. • Provides tools and resources to promote and facilitate access to preventive and other important health services. • Supports the development of facility site review policies, procedures and processes. • Identifies and supports ongoing program improvement opportunities and initiatives. • Provides technical assistance to providers, medical groups, and internal partners to enable delivery of accessibility information to Molina members. • Participates in PARS trainings, internal/departmental/collaborative meetings, workgroups and completes required compliance trainings to maintain necessary knowledge and skills. • Maintains confidentiality and compliance with Health Insurance Portability and Accountability Act (HIPAA) standards. • Collaborates with leadership to establish individual and team goals. • Completes special assignments and projects as assigned. Job Qualifications REQUIRED QUALIFICATIONS: • At least 2 years of related clinical/quality review experience, or equivalent combination of relevant education and experience. • Active and unrestricted Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) in state of practice. This position requires same-day out-of-office travel 50- 75% of the time, depending on location. (on average the nurses are in the field 3-4 days per week) This position may require multiple days’ out of town overnight travel 0 - 30% of the time, depending upon location. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and situations. • Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. • Critical thinking skills. • Proactive, detail oriented, and organized. • Ability to work cross-functionally across a highly matrixed organization. • Effective verbal and written communication skills. • Microsoft Office suite and applicable software programs proficiency. PREFERRED QUALIFICATIONS: • Managed care experience. • Quality improvement and/or auditing experience. • Successful completion of PARS training and/or PARS certification. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $30.37 - $55 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.