Overview

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.

Additional Benefits

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 salary
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account - Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

1. Audit medical necessity claims in accordance with departmental policies and procedures
2. Act as the key clinical interface between the Claims and Medical Services departments
3. Attend UM and Claims team meetings
4. Review inpatient and outpatient claims that require authorization, appeals and other disputed claims in a timely manner to meet regulatory requirements
5. Obtain the appropriate clinical information necessary to make authorization decisions for unauthorized claims
6. Identify potential denied services/admissions/days and present to the Medical Director, both Plan and Direct, for appropriate decision/direction
7. Review medical records to determine if charges and/or services are appropriate (e.g., reviewing CPT/HCPCS codes, up-coding practices, and similar items)
8. Analyze level of care on in-patient reviews. Track trends in billing patterns by provider and report to leadership practices that may need further investigation
9. Develop and sustain positive working relationships, collaborating with physicians, nurses, ancillary personnel and all others as appropriate to promote open communication channels, obtain/disseminate information, and enhance customer relations
10. Inform appropriate staff for coordination and negotiation of financial arrangements for non-contracted and/or fee-for-service providers and facilities
11. Provide reports as necessary
12. Adapt to changes or unusual circumstances to promote cooperation and minimize disruption of working environment
13. Perform any other duties as required to ensure Health Plan operations and department business needs are successful

• A minimum of one (1) year of relevant work experience
• Recent experience with inpatient and outpatient utilization and case management required
• Experience in auditing claims
  • Experience in reviewing inpatient medical records and claims preferred
  • Experience in managed care, MediCal, Medicare preferred
• High school diploma or GED
  • Associate's degree in health care or a related field from an accredited institution
• Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required

• Knowledge and understanding of:
  • CPT, ICD-10, HCPCS and hospital revenue codes
  • Nationally recognized clinical criteria (e.g., InterQual, Milliman, Apollo)
  • Medi-Cal, Medicare and other state/federal Program & Regulations
  • Foundations of nursing practice and clinical pathways across inpatient, outpatient, and post-acute settings
  • Health plan policies, prior authorization protocols, appeals processes, and denial management
  • Proficient in computer applications such as Word and Excel
  • Skilled in Data Entry
  • Skilled clinical review and judgement
  • Data analysis and trend identification skills
  • Communication skills (both written and verbal)
• Proven ability to:
  • Exercise sound clinical judgement with minimal supervision
  • Escalate appropriately to Medical Director for complex determinations
  • Build trust and collaboration with physicians, nurses, ancillary staff, and claims personnel
  • Navigates diverse perspectives
  • Adjust to policy updates, workflow changes, and unusual circumstances while maintaining service quality
  • Handle PHI with strict adherence to privacy and security standards; maintains ethical audit practices
  • Possess a strong attention to detail with the ability to multi-task