Licensed Practical Nurse - Utilization Review
Apply NowCompany: TotalMed
Location: Orange, CA 92867
Description:
Licensed Practical Nurse-Utilization Review
Job ID #1786092
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About this Role
The Grievance and Appeals Nurse Specialist participates in managing medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests. The incumbent will ensure appeals and state hearing requests are processed in accordance with regulations, compliance standards and policies and procedures. The incumbent will investigate and prepare case narratives and statements of position based on clinical information, benefits and applicable regulations related to member or provider disputes of decisions. The incumbent will clearly articulate the facts and position regarding disputes to the Administrative Law Judge hearing the case. The incumbent will be responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements.
Job details
$43.66 / hour
Orange, California
New
Profession: Licensed Practical Nurse
Facility Type: ???
Specialty: Utilization Review
Division: MedFi
Start Date: 04/28/2025
Apply
Responsibilities
Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions.
Ensures all cases are completed in accordance with state and federal regulatory requirements including timelines.
Presents recommendations based on clinical review, criteria and organizational policies to physician reviewers for final determination.
Resolves complex and sensitive member issues within established timelines.
Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases.
Analyzes and reports cases through GARS' subcommittee
Oversees state hearing cases.
Discusses appeal process, medical decisions and hearing rights with members.
Assists members in coordinating their services with providers and communicates the status and outcome to members.
Required Qualifications
Active Licensed Vocational Nurse (LVN) license to practice in the state of California required. - RN license preferred
5 years of health care/managed care experience required. Preferably in the following related areas of responsibility: Grievances and Appeals, Utilization Management and/or Quality Management.
An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Bilingual in English and Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese preferred
Job ID #1786092
| Share
About this Role
The Grievance and Appeals Nurse Specialist participates in managing medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests. The incumbent will ensure appeals and state hearing requests are processed in accordance with regulations, compliance standards and policies and procedures. The incumbent will investigate and prepare case narratives and statements of position based on clinical information, benefits and applicable regulations related to member or provider disputes of decisions. The incumbent will clearly articulate the facts and position regarding disputes to the Administrative Law Judge hearing the case. The incumbent will be responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements.
Job details
$43.66 / hour
Orange, California
New
Profession: Licensed Practical Nurse
Facility Type: ???
Specialty: Utilization Review
Division: MedFi
Start Date: 04/28/2025
Apply
Responsibilities
Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions.
Ensures all cases are completed in accordance with state and federal regulatory requirements including timelines.
Presents recommendations based on clinical review, criteria and organizational policies to physician reviewers for final determination.
Resolves complex and sensitive member issues within established timelines.
Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases.
Analyzes and reports cases through GARS' subcommittee
Oversees state hearing cases.
Discusses appeal process, medical decisions and hearing rights with members.
Assists members in coordinating their services with providers and communicates the status and outcome to members.
Required Qualifications
Active Licensed Vocational Nurse (LVN) license to practice in the state of California required. - RN license preferred
5 years of health care/managed care experience required. Preferably in the following related areas of responsibility: Grievances and Appeals, Utilization Management and/or Quality Management.
An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Bilingual in English and Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese preferred