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LPN Clinical Reviewer
North Little Rock, Arkansas · HealthcareFantastic North Little Rock Opportunity for an Experienced LPN Clinical Reviewer. Reviewer is responsible for the pre-certification of Plan determined procedures utilizing approved guidelines.
ESSENTIAL DUTIES AND RESPONSIBILITIES include but not limited to:
Must have Current LPN License and minimum of 3 years CLINIC nursing experience.
Monday-Friday, 8am-4:30pm! Direct Hire position!
Great Benefits & Perks!
ESSENTIAL DUTIES AND RESPONSIBILITIES include but not limited to:
- Clinical review of precertification. This includes examining plan provisions and clinical guidelines to determine if the proposed treatment is covered including chemical dependency, bariatric, and transplant services.
- Utilization and claims review including but not limited to the following claims:
- NDC number repricing
- DRG
- Case Rates
- Stop Loss
- High Dollar
- Refers cases to supervisor and/or medical director for review as necessary.
- Reviews claim investigations and miscellaneous claims for coverage determination.
- Acts as provider liaison for clinical related issues.
- Answers questions from providers and members regarding precertification and benefits.
- Reports status of ongoing tasks to supervisor.
- Administers inoculations when needed.
- Assists with provider and member outreach as requested.
- Attends staff meetings as required.
- Prepares correspondence as needed.
- Complies with the company's Cybersecurity Training Policy and HIPAA training and confidentiality requirements
- Provides support help for staff as needed.
- Regular and timely attendance required.
- Adhere to quality standards and confidentiality policies and procedures.
- Performs any other duties as required or assigned.
Must have Current LPN License and minimum of 3 years CLINIC nursing experience.
Monday-Friday, 8am-4:30pm! Direct Hire position!
Great Benefits & Perks!