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LPN/Medical Reviewer (KS-apm)

Nursing | Columbia, SC | Full Time

Job Description

LPN/Medical Reviewer

We have an opportunity for an LPN/Medical Reviewer to come and join our client located in Columbia, SC! As the LPN/Medical Reviewer with a large health insurance provider, you will be responsible for reviewing and evaluating medical or behavior eligibilities regarding benefits and clinical criteria. You’ll successfully complete these highly important assignments by applying clinical expertise, administrative policies and previous established clinical criteria.  So, if you’re ready to join an organization that serves millions of South Carolinians, apply today!

Overall Purpose of the Position:

Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals.  Documents decisions using indicated protocol sets or clinical guidelines.  Provides support and review of medical claims and utilization practices.

Responsibilities of Job:

May provide any of the following in support of medical claims review and utilization review practices:

  • Performs medical claim reviews and makes a reasonable charge payment determination.  Monitors process's timeliness in accordance with contractor standards.  Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
  • Utilizes allocated resources to back up review determination.  Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process. 
  • May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.  Performs screenings/assessments and determines risk via telephone.  Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
  • Provides education to members and their families/caregivers.  Reviews first level appeal and ensures utilization or claim review
  • Provides thorough documentation of each determination and basis for each.  Conducts research necessary to make a thorough/accurate basis for each determination made.
  • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.  Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
  • Participates in quality control activities in support of the corporate and team-based objectives.  Participates in all required training.

Qualifications:

  • Active & unrestricted LPN license in South Carolina  
  • Minimum of 2 years clinical experience
  • Solid computer skills
  • Excellent attention to detail
  • Ability to work independently

We support a diverse workforce and is an Equal Opportunity Employer who does not discriminate against employees and applicants for employment on the basis of race, gender, color, religion, national origin, age, sexual orientation, gender identity, genetic information, disability, veteran status, or other classification protected by law.