Job Information
Insight Global UM LVN in Irvine, California
Job Description
Under the general direction of the Director of UM, UM Manager, and the UM Supervisor, the Prior Authorization LVN ensures that prior authorization requests from patients and providers are completed in a timely fashion to meet the contractual and regulatory requirements while acting within the scope of their licensure. The Prior Authorization LVN will promote the quality and cost effectiveness of medical care provided to patients by applying clinical acumen and using appropriate nationally recognized guidelines, criteria, and evidence based standards. Also assists UM management and Compliance team in preparation for audits and other regulatory activities as needed.
Primary Responsibilities:
1 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.
2 Coordinate and follow established prior authorization review process for outpatient and inpatient service requests.
3 Collaborates as directed with the Case Management Department or other departments as needed.
4 Accurate, thorough, and efficient review of prior authorization requests.
5 Timely review of prior authorization requests to include acute hospital pre-admission, surgical and diagnostic procedures, therapies, durable medical equipment, and home health care.
6 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.
7 Audits and evaluates patient medical records when determining benefit coverage and medical necessity, including appropriateness and level of care.
8 Reviews prior authorization requests in coordination with group Medical Directors as required.
9 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.
10 Assists in processing denial and extension letters using appropriate language, health literacy level, criteria, and policies.
We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to HR@insightglobal.com .
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Skills and Requirements
LVN license in the state of CA
1-2 years of UM experience OR reverse review experience and have been in an office or clinical setting
Basic CPT and ICD-9 coding
Computer savvy null
We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal employment opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment without regard to race, color, ethnicity, religion,sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military oruniformed service member status, or any other status or characteristic protected by applicable laws, regulations, andordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or the recruiting process, please send a request to HR@insightglobal.com.