Claims Review Nurse, LVN (Remote)

Inland Empire Health Plan•Rancho Cucamonga, CA

3d•$63,898 - $83,075•Remote

About The Position

Reporting to the Supervisor, Integrated Transitional Care, the Claims Review Nurse, LVN is responsible for conducting timely medical reviews of IEHP facility and professional claims and appeals. The Claims Review Nurse, LVN identifies process improvements in the UM/Claims interface and makes recommendations to improve the claim authorization process and business rules between Claims and UM teams. The Claims Review Nurse, LVN exercises independent judgment in conducting claims reviews and supports key clinical determinations in alignment with guidance from the Supervisor, Integrated Transitional Care. The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, 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
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 unencunmbered 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 and understanding of: Nationally recognized clinical criteria (e.g., InterQual, Milliman, Apollo)
Knowledge and understanding of: Medi-Cal, Medicare and other state/federal Program & Regulations
Knowledge and understanding of: Foundations of nursing practice and clinical pathways across inpatient, outpatient, and post‑acute settings
Knowledge and understanding 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)
Proven ability to: Exercise sound clinical judgement with minimal supervision
Proven ability to: Escalate appropriately to Medical Director for complex determinations
Proven ability to: Build trust and collaboration with physicians, nurses, ancillary staff, and claims personnel
Proven ability to: Navigates diverse perspectives
Proven ability to: Adjust to policy updates, workflow changes, and unusual circumstances while maintaining service quality
Proven ability to: Handle PHI with strict adherence to privacy and security standards; maintains ethical audit practices
Proven ability to: Possess a strong attention to detail with the ability to multi-task

Nice To Haves

Experience in reviewing inpatient medical records and claims preferred
Experience in managed care, MediCal, Medicare preferred

Responsibilities

Audit medical necessity claims in accordance with departmental policies and procedures
Act as the key clinical interface between the Claims and Medical Services departments
Attend UM and Claims team meetings
Review inpatient and outpatient claims that require authorization, appeals and other disputed claims in a timely manner to meet regulatory requirements
Obtain the appropriate clinical information necessary to make authorization decisions for unauthorized claims
Identify potential denied services/admissions/days and present to the Medical Director, both Plan and Direct, for appropriate decision/direction
Review medical records to determine if charges and/or services are appropriate (e.g., reviewing CPT/HCPCS codes, up-coding practices, and similar items)
Analyze level of care on in-patient reviews. Track trends in billing patterns by provider and report to leadership practices that may need further investigation
Develop and sustain positive working relationships, collaborating with physicians, nurses, ancillary personnel and all others as appropriate to promote open communication channels, obtain/disseminate information, and enhance customer relations
Inform appropriate staff for coordination and negotiation of financial arrangements for non-contracted and/or fee-for-service providers and facilities
Provide reports as necessary
Adapt to changes or unusual circumstances to promote cooperation and minimize disruption of working environment
Perform any other duties as required to ensure Health Plan operations and department business needs are successful