LVN - Quality Assurance/Utilization Review - Business Development - Full Time 8hr
About The Position
The Utilization Review Nurse will evaluate medical records to determine medical necessity by applying clinical acumen and the appropriate application of policies and guidelines to urgent and standard reviews. This role involves documenting decisions using indicated protocol sets or clinical guidelines, providing support and review of medical claims and utilization practices, and completing medical necessity and level of care reviews for requested services using clinical judgment. The nurse will also refer cases to Medical Directors for review depending on case findings.
Requirements
- Minimum of three years of utilization management experience
- Computer proficiency is required
- Excellent customer service skills required
- Current California LVN license
Nice To Haves
- Experience in quality- related job preferred
Responsibilities
- Evaluate medical records to determine medical necessity by applying clinical acumen and the appropriate application of policies and guidelines to urgent and standard reviews
- Document decisions using indicated protocol sets, or clinical guidelines
- Provide support and review of medical claims and utilization practices
- Complete medical necessity and level of care reviews for requested services using clinical judgment
- Refer to Medical Directors for review depending on case findings
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
501-1,000 employees
