Remote LPN Medical Reviewer I - Utilization Management Specialist

We are seeking a highly skilled and detail-oriented LPN Medical Reviewer I to join our team as a Utilization Management Specialist. As a key member of our medical review team, you will be responsible for performing medical reviews, utilization management, and appeals using established criteria sets and clinical guidelines. This is a full-time, remote opportunity after completing 6 months of on-site training, offering a unique chance to work from home and contribute to the delivery of high-quality healthcare services.

Key Responsibilities

• Perform medical reviews and make reasonable charge payment determinations
• Monitor process timeliness and ensure compliance with contractor standards
• Conduct authorization processes, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines
• Utilize allocated resources to back up review determinations and provide education to members and their families/caregivers
• Participate in quality control activities and maintain accurate documentation of all determinations and basis for each

Requirements

• Bachelor's degree in Social Work or graduate of an accredited school of Licensed Practical Nursing or Licensed Vocational Nursing
• 2 years of clinical experience
• Active, unrestricted LPN/LVN licensure from the United States and in the state of hire
• Working knowledge of word processing software and good judgment, customer service, and organizational skills

Preferred Qualifications

• Associate Degree in Nursing or graduate of an accredited school of nursing
• Working knowledge of spreadsheet and database software
• Demonstrated oral and written communication skills and ability to persuade, negotiate, or influence others

What We Offer

• Comprehensive benefits package, including subsidized health plans, dental and vision coverage, 401k retirement savings plan, and life insurance
• Paid Time Off (PTO) and education assistance
• Opportunities for professional growth and development in a diverse and inclusive workplace

How to Apply

If you are a motivated and detail-oriented individual with a passion for delivering high-quality healthcare services, please submit your application, including your resume and a cover letter, to be considered for this exciting opportunity.