Offer summary

Qualifications:

LPN with a valid, unrestricted clinical license in the state of operations., Minimum of 3 years of clinical experience in a physician office, hospital, or surgical setting., Strong verbal and written communication skills, along with interpersonal skills., Familiarity with PC or database systems and customer service orientation..

Key responsibilities:

Conduct pre-authorization reviews in accordance with medical contracts and regulations.

Collaborate with healthcare providers, members, and business partners to optimize member benefits.

Evaluate medical necessity for various services including inpatient admissions and outpatient services.

Promote effective use of resources and ensure quality of care.

Job description

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

Join HCSC and be part of a purpose-driven company that will invest in your professional development.

Job Summary

This position is responsible for pre-authorization reviews in accordance with the medical contract and regulations, medical criteria, utilization review, and quality of care. Responsible for collaborating with healthcare providers, members, and business partners, to optimize member benefits, evaluate medical necessity and promote effective use of resources. Medical necessity reviews may include: inpatient admissions, outpatient services, surgical and diagnostic procedures, home health, durable medical equipment and out of network services.

JOB REQUIREMENTS:

LPN with valid, current, unrestricted clinical license in the state of operations.
3 years of clinical experience in physician office, hospital, or surgical setting.
Customer service oriented to assist internal/external customers.
Verbal and written communication skills.
Interpersonal skills and ability to be a team player.
Willingness and ability to travel.
Familiar with PC or database systems.
Incumbents with nursing licenses in positions/departments requiring multi-state licenses are required to obtain and maintain additional current, valid, and unrestricted applicable nursing licenses in other states as determined by management. Multi-state license fees will be provided by HCSC. Incumbents with other clinical licenses are not required to obtain multi-state licenses.

PREFERRED JOB REQUIREMENTS:

LPN / LVN Multi-state License Preferred
Utilization review or utilization management experience
Strong organizational, planning, and communication skills
Working knowledge of insurance industry, medical coding (CPT/HCPCS/ICD-10)
Knowledge of National Coverage Determinations, Local Coverage Determinations and MCG criteria are a plus.

Work Schedule: Weekend Rotation and Holiday Rotation (2 holidays per year)

This is a Telecommute (Remote) role: Must reside within 250 miles of the office or anywhere within the posted state.

#LI-DP1

#CA

#LI - REMOTE

Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

Pay Transparency Statement:

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.