About the position 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 rendering services to 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 completing and reviewing denial letters in accordance with Texas Department of Insurance (TDI) and/or Centers for Medicare & Medicaid Services (CMS) and health plan 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 policies and procedures, new techniques, and additional responsibilities as assigned to meet changing business needs.

Responsibilities

• Conduct medical reviews, benefit verification, and apply criteria to determine medical necessity for health care services requiring authorization prior to rendering services to members.
• Serve as a liaison in reviewing requests for medical and surgical procedures, services and admissions.
• Communicate with providers regarding pertinent information needed for medical review to ensure service decisions are determined within appropriate timeframes.
• Serve as a liaison to the Grievance and Appeals Department for Medicare Advantage appeals.
• Complete and review denial letters in accordance with Texas Department of Insurance (TDI) and/or Centers for Medicare & Medicaid Services (CMS) and health plan requirements.
• Serve as liaison and primary point of contact for add-on procedures performed at the KS Ambulatory Surgery Center (ASC).
• Support Utilization Review quality assurance initiatives, including mock audits, to ensure compliance.
• Be flexible and adapt to changes in policies and procedures, new techniques, and additional responsibilities as assigned to meet changing business needs.

Requirements

• Licensed Vocational Nurse
• Active Texas RN license or multistate compact RN license
• 5+ years of utilization review experience at a health plan, ACO, IPA, or provider group
• HMO, PPO, and POS insurance knowledge

Nice-to-haves

• CEU requirements must be maintained
• Certification in area of specialization
• Experience working with insurance (HMO, PPO, and POS) companies to obtain authorizations and pre-certification for medical services
• Consistent and prompt attendance at employer worksite is an essential job requirement
• Proven excellent verbal and communication skills, and organizational skills
• Proven solid organization and communication skills
• Bilingual
• Active Driver’s License

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution