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 services being rendered for 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.
The Utilization Review Specialist (LVN) is responsible for completion and review of denial letters based on Texas Department of Insurance (TDI) and or Centers for Medicare and Medicaid (CMS) and healthplan 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 polices and procedures, new techniques, and additional responsibilities as assigned to meet changing business needs.
Job Title: Utilization Review Specialist Licensed Vocation Nurse (LVN) – KCA Utilization Management
Clinic Location: Pearland Administrative Office
Department: KCA Utilization Management
Job Type: Full Time
Salary Range: $59,108 – $73,025 (Pay is based on several factors including but not limited to education, work experience, certifications, etc.)
Required: Licensed Vocational Nurse; CEU requirement
Preferred: Certification in area of specialization
Required: 5 years utilization review experience at a health plan, ACO, IPA, or provider group or 3 years clinical nursing experience
Required: TX LVN license, Valid Driver’s license
Required: Excellent verbal and communication skills, and organizational skills
Required: Experience working with insurance (HMO, PPO, and POS) companies to obtain authorizations and pre-certification for medical services. Ability to work from designated office for collaborative / interactive fulfilment of duties; ability to concentrate in an open-office cubicle environment; interact with other staff members and / or outside associates; perform telephone and / or computer work for extended periods of time; operate office equipment such as a computer, telephone, and copy / scan / fax machine; actively participate in department meetings via phone, computer or in person. Consistent and prompt attendance at employer worksite is an essential job requirement
Working Environment: Clinic
Start your career journey and become a part of a community of renowned Healthcare professionals. Kelsey-Seybold Clinic is Houston’s fastest growing, multispecialty organization with more than 40 premier locations and over 65 specialties. Our clinics are comprised of more than 600 physicians and as we continue to grow, our focus is providing quality patient care by adding to our team of clinical and non-clinical professionals that work together in a convenient, coordinated, and collaborative manner. Enjoy the rewards of a successful career while maintaining a work/life balance by joining our team today and changing the way health cares.
Why Kelsey-Seybold Clinic?
- Medical, Vision, and Dental
- Tuition Reimbursement
- Company Matching 401K
- Employee Reward and Recognition Program
- Paid time off for vacation, sick, and holidays
- Employee Assistance Program
- Continuing Medical Education allowance
Utilization Review Specialist Licensed Vocation Nurse (LVN) – KCA Utilization Management