Claims Review Nurse, LVN (Remote)

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Reporting to the Supervisor, Integrated Transitional Care, the Claims Review Nurse, LVN is responsible for conducting timely medical reviews of IEHP facility and professional claims and appeals. The Claims Review Nurse, LVN identifies process improvements in the UM/Claims interface and makes recommendations to improve the claim authorization process and business rules between Claims and UM teams. The Claims Review Nurse, LVN exercises independent judgment in conducting claims reviews and supports key clinical determinations in alignment with guidance from the Supervisor, Integrated Transitional Care. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salaryState of the art fitness center on-siteMedical Insurance with Dental and VisionLife, short-term, and long-term disability optionsCareer advancement opportunities and professional developmentWellness programs that promote a healthy work-life balanceFlexible Spending Account – Health Care/ChildcareCalPERS retirement457(b) option with a contribution matchPaid life insurance for employeesPet care insurance Education & Experience A minimum of one (1) year of relevant work experienceRecent experience with inpatient and outpatient utilization and case management requiredExperience in auditing claimsExperience in reviewing inpatient medical records and claims preferredExperience in managed care, MediCal, Medicare preferredHigh school diploma or GEDAssociate’s degree in health care or a related field from an accredited institutionPossession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required Key Qualifications Knowledge and understanding of:CPT, ICD-10, HCPCS and hospital revenue codesNationally recognized clinical criteria (e.g., InterQual, Milliman, Apollo)Medi-Cal, Medicare and other state/federal Program & RegulationsFoundations of nursing practice and clinical pathways across inpatient, outpatient, and post‑acute settingsHealth plan policies, prior authorization protocols, appeals processes, and denial managementProficient in computer applications such as Word and ExcelSkilled in Data EntrySkilled clinical review and judgementData analysis and trend identification skillsCommunication skills (both written and verbal)Proven ability to: Exercise sound clinical judgement with minimal supervisionEscalate appropriately to Medical Director for complex determinationsBuild trust and collaboration with physicians, nurses, ancillary staff, and claims personnelNavigates diverse perspectivesAdjust to policy updates, workflow changes, and unusual circumstances while maintaining service qualityHandle PHI with strict adherence to privacy and security standards; maintains ethical audit practicesPossess a strong attention to detail with the ability to multi-task Start your journey towards a thriving future with IEHP and apply TODAY! Pay Range $63,897.60 USD Annually - $83,075.20 USD Annually