Medical Reviewer LPN # 26-13483

Responsibilities

• Reviews clinical for pre-certifications for durable medical equipment, home health care and elective procedures.
• Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals.
• Documents decisions using indicated protocol sets or clinical guidelines.
• Sets up and monitors the timeliness of the process in accordance with contractor standards.
• Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
• Utilizes allocated resources to back up review determination.
• Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
• Conducts/Performs high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.
• Conducts screenings/assessments and determines risk via telephone.
• Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
• Provides education to members and their families/caregivers.
• Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each.
• Conducts research necessary to make thorough/accurate basis for each determination made.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• Participates in quality control activities in support of the corporate and team-based objectives.

Requirements

• 2 years’ clinical experience.

Skills

• Working knowledge of word processing software.
• Knowledge of quality improvement processes and demonstrated ability with these activities.
• Knowledge of contract language and application.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills.
• Demonstrated customer service, organizational, and presentation skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Demonstrated oral and written communication skills.
• Ability to persuade, negotiate, or influence others.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.

Qualifications

• Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing.

Additional Qualifications

• Licenses: Active SC unrestricted LPN licensure.
• Certifications: N/A.

Shift Hours

Monday through Friday, 8:30AM-5:00PM.

About Us

Tech Solutions US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com. US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

AI Statement

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