LPN/LVN  - Prior Authorization Nurse
Location: Remote (PST Time Zone)
Hours: 8am-5pm PST

Summary:
The LVN Prior Authorization Nurse will be responsible for conducting concurrent reviews and providing prior authorizations for medical treatments and procedures in accordance with state and federal regulations. This role will collaborate with internal and external stakeholders to ensure members receive appropriate care. The ideal candidate will possess strong organizational skills, clinical expertise, and proficiency in utilizing Microsoft Office products.

Essential Functions:

• Conduct concurrent reviews and prior authorizations for medical treatments and procedures.
• Determine appropriate benefits, eligibility, and expected length of stay for members.
• Collaborate with interdisciplinary teams to ensure continuity of care for members.
• Maintain productivity and quality measures within the department.
• Complete assigned work plan objectives and projects in a timely manner.
• Foster professional relationships with providers and internal/external customers.
• Consult with medical directors and refer cases as necessary.
• Adhere to workplace safety standards and company Code of Conduct.

Knowledge/Skills/Abilities:

• Strong communication, problem-solving, and interpersonal skills.
• Excellent organizational abilities with the capacity to manage multiple priorities.
• Proficiency in Microsoft Office products, particularly Excel.
• Knowledge of applicable state and federal regulations.
• Familiarity with Interqual and other references for medical necessity determinations.
• Experience with NCQA standards.
• Ability to work independently and take initiative.
• Commitment to maintaining confidentiality and HIPAA compliance.
• Skilled at establishing and maintaining positive work relationships.

Requirements:

• Education: Completion of an accredited LVN/LPN program. 

• Experience: Minimum of 2-4 years of clinical practice, with preference given to candidates with experience in hospital nursing, utilization management, or case management. Experience with Microsoft excel.

• Licensure/Certification: Active, unrestricted California State Nursing (LVN) license in good standing.

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