Utilization Mgmt LVN - Kelsey Seybold Pearland

The Utilization Review LVN nurse will perform documentation review for medical necessity and benefit correlation of requested medical and surgical procedures, services and admissions for HMO, PPO and POS products. The UR LVN nurse will serve as facilitator of communication with clinic, payor and other customers.

Primary Responsibilities

• Data entry of all UR requests into the Kelsey-Seybold data system
• Verifies eligibility
• Obtains benefit interpretation from insurance company
• Reviews request and chart to determine medical necessity by using internal criteria
• Approves request or defers to insurance review and assists with MD review
• Communicates with respective payor to obtain pre-certification authorization
• Serves as resource to physicians, staff and patients regarding review process
• Clarifies UR request discrepancies with office submitting or insurance company
• Other duties as assigned

Required Qualifications

• Licensed Vocational Nurse, CEU requirement
• TX LVN license, Valid Driver's license
• 3+ years diverse clinical experience, including acute care or similar care
• 2+ years utilization review experience at heath plan, ACO, IPA, or provider group OR
• HMO, PPO and POS insurance knowledge
• Proven good organization and communication skills

Preferred Qualification

• Computer and Coding experience

The hourly pay for this role will range from $20 - $36 per hour based on full-time employment.