LVN Utilization Review Specialist - Kelsey Seybold Clinic: Remote

UnitedHealth Group•Pearland, TX

5d•$20 - $36•Remote

About The Position

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation’s leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together. The Utilization Review Specialist (LVN) is responsible for conducting medical reviews, benefit verification, and applying criteria to determine medical necessity for health care services requiring authorization prior to rendering services to members. The Utilization Review Specialist (LVN) serves as a liaison in reviewing requests for medical and surgical procedures, services and admissions. The Utilization Review Specialist communicates with providers regarding pertinent information needed for medical review to ensure service decisions are determined within appropriate timeframes. This position will serve as a liaison to the Grievance and Appeals Department for Medicare Advantage appeals. If you are located in Texas, you will have the flexibility to work remotely as you take on some tough challenges. The Utilization Review Specialist (LVN) is responsible for completing and reviewing denial letters in accordance with Texas Department of Insurance (TDI) and/or Centers for Medicare & Medicaid Services (CMS) and health plan requirements. The Utilization Review Specialist (LVN) will serve as liaison and primary point of contact for add-on procedures performed at the KS Ambulatory Surgery Center (ASC). The Utilization Review Specialist (LVN) will support the Utilization Review quality assurance initiatives, including mock audits, to ensure compliance. The Utilization Review Specialist will be flexible and adapt to changes in policies and procedures, new techniques, and additional responsibilities as assigned to meet changing business needs You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Requirements

Licensed Vocational Nurse.
CEU requirements must be maintained
TX LVN license
5+ years of utilization review experience at a health plan, ACO, IPA, or provider group
HMO, PPO, and POS insurance knowledge
Valid Driver’s license

Nice To Haves

Certification in area of specialization
Bilingual
Experience working with insurance (HMO, PPO, and POS) companies to obtain authorizations and pre-certification for medical services
Consistent and prompt attendance at employer worksite is an essential job requirement
Excellent verbal and communication skills, and organizational skills
All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Responsibilities

Conducting medical reviews
Benefit verification
Applying criteria to determine medical necessity for health care services requiring authorization prior to rendering services to members
Serves as a liaison in reviewing requests for medical and surgical procedures, services and admissions
Communicates with providers regarding pertinent information needed for medical review to ensure service decisions are determined within appropriate timeframes
Serve as a liaison to the Grievance and Appeals Department for Medicare Advantage appeals
Completing and reviewing denial letters in accordance with Texas Department of Insurance (TDI) and/or Centers for Medicare & Medicaid Services (CMS) and health plan requirements
Serve as liaison and primary point of contact for add-on procedures performed at the KS Ambulatory Surgery Center (ASC)
Support the Utilization Review quality assurance initiatives, including mock audits, to ensure compliance
Be flexible and adapt to changes in policies and procedures, new techniques, and additional responsibilities as assigned to meet changing business needs