Utilization Review Spec LVN Remote – Kelsey Seybold Clinics, TX

2338837 Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation’s leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.   General Role Description:

• 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

  You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications:

• 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

  Preferred Qualifications:

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

  Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $20.38 to $36.44 per hour based on full-time employment. We comply with all minimum wage laws as applicable.   Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.   At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes – an enterprise priority reflected in our mission.