Job description
Overview:
With 55 different clinical and non-clinical specialties, you can design a career path at Kelsey-Seybold Clinic that allows you to grow your future in a completely new direction.
Kelsey-Seybold Clinic is changing the way health cares. Responsibilities:
EDUCATION REQUIREMENTS & EXPERIENCE REQUIREMENTS
Education
A.
Certification in area of specialization
Experience
A.
5 years utilization review experience at a health plan, ACO, IPA, or provider group or 3 years clinical nursing experience
B.
Licenses
A.
TX LVN license, Valid Driver’s license
B.
Communication
A.
B.
Special Skills
A.
Other
A.
WORKING ENVIRONMENT
Kelsey-Seybold Clinic, a Houston tradition in patient-centered care, is a multispecialty clinic with over 25 locations and comprises more than 500 physicians providing primary and specialty care in a collaborative manner.
With 55 different clinical and non-clinical specialties, you can design a career path at Kelsey-Seybold Clinic that allows you to grow your future in a completely new direction.
Kelsey-Seybold Clinic is changing the way health cares.
The Utilization Review Specialist (LVN) is responsible for conducting medical reviews, benefit verification, and applying criteria to determine medical necessity for health care services requiring authorization prior to services being rendered for members. The Utilization Review Specialist (LVN) serves as a liaison in reviewing requests for medical and surgical procedures, services and admissions. The Utilization Review Specialist communicates with providers regarding pertinent information needed for medical review to ensure service decisions are determined within appropriate timeframes. This position will serve as a liaison to the Grievance and Appeals Department for Medicare Advantage appeals.
The Utilization Review Specialist (LVN) is responsible for completion and review of denial letters based on Texas Department of Insurance (TDI) and or Centers for Medicare and Medicaid (CMS) and healthplan requirements. The Utilization Review Specialist (LVN) will serve as liaison and primary point of contact for add on procedures performed at the KS Ambulatory surgery center (ASC). The Utilization Review Specialist (LVN) will support the Utilization Review quality assurance initiatives including mock audits to ensure compliance. The Utilization Review Specialist will be flexible and adapt to changes in polices and procedures, new techniques, and additional responsibilities as assigned to meet changing business needs.
Qualifications:
Utilization Review Specialist (LVN)
Location: Pearland Administrative Office
Department: Utilization Management
Job Type: Full Time
EDUCATION REQUIREMENTS & EXPERIENCE REQUIREMENTS
(A = basics; B = preferred)
Education
A.
Licensed Vocational Nurse; CEU requirement
B.
Certification in area of specialization
Experience
A.
5 years utilization review experience at a health plan, ACO, IPA, or provider group or 3 years clinical nursing experience
B.
Licenses
A.
TX LVN license, Valid Driver’s license
B.
Communication
A.
B.
Special Skills
A.
Excellent verbal and communication skills, and organizational skills
B.
Other
A.
Experience working with insurance (HMO, PPO, and POS) companies to obtain authorizations and pre-certification for medical services. Ability to work from designated office for collaborative / interactive fulfilment of duties; ability to concentrate in an open-office cubicle environment; interact with other staff members and / or outside associates; perform telephone and / or computer work for extended periods of time; operate office equipment such as a computer, telephone, and copy / scan / fax machine; actively participate in department meetings via phone, computer or in person. Consistent and prompt attendance at employer worksite is an essential job requirement.
B.
Bilingual
WORKING ENVIRONMENT
Clinic
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