Utilization Management LPN
The Judge Group Inc.

Job Info

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Location: Redlands, CA
Salary: $30.00 USD Hourly - $31.00 USD Hourly
Description:
Judge Healthcare is seeking a LPN for an opening with one of our top clients in the Redlands, CA area ASAP!

Position Details:

Title: Utilization Management / Prior Authorization LPN

Location: Redlands, CA 92374

Type of engagement: Contract

Hours: M-F 8am-5pm PST

Specific Duties:

• Acting within the scope of their license, ensures that prior authorization requests are appropriately reviewed and completed in a timely manner to meet contractual and regulatory requirements.
• Coordinate and follow established prior authorization review process for outpatient and inpatient service requests.
• Collaborates as directed with the Case Management Department or other departments as needed.
• Accurate, thorough, and efficient review of prior authorization requests.
• Timely review of prior authorization requests to include acute hospital pre-admission, surgical and diagnostic procedures, therapies, durable medical equipment, and home health care.
• Conducts medical determinations based on nationally recognized and evidence based guidelines, and in accordance with the policies and procedures approved by the physician group Medical Directors and UM Committees.
• Audits and evaluates patient medical records when determining benefit coverage and medical necessity, including appropriateness and level of care.
• Reviews prior authorization requests in coordination with group Medical Directors as required.
• Assists UM Coordinators and other clerical staff with issues and concerns that require clinical interpretation or definition including assisting patients with interpretation of criteria used in determinations as requested.
• Assists in processing denial and extension letters using appropriate language, health literacy level, criteria, and policies.
  

Requirements/Qualifications:

• Graduate of an accredited school of nursing required.
  
• One year clinical experience in an acute or ambulatory patient care setting including one year in a managed care environment such as a medical group, independent physician association, or health plan is required.
  
• Ability to work efficiently and effectively in multiple different utilization management software applications
• Must be proficient in the application of Microsoft Word, Excel, Outlook, and the Internet.
• Knowledge of Medicare, DMHC, NCQA, and MCG Guidelines
• Understanding of concepts and principles of managed care
  

Please send your resume and the job number to Sophia Kranias at SCosciaKranias@judge.com for immediate consideration and please share within your network!

Thank you for your time and I look forward to hearing from and working with you.

Regards,

Sophia Kranias

Healthcare Recruiter

The Judge Group

Email: scosciakranias@judge.com

Contact: scosciakranias@judge.com

This job and many more are available through The Judge Group. Find us on the web at www.judge.com

This job has expired.