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The Prior Authorization LVN ensures that prior authorization requests from patients and providers are completed in a timely fashion to meet the contractual and regulatory requirements while acting within the scope of the Board of Vocational Nursing and Psychiatric Technicians of the State of California. The Prior Authorization LVN will promote the quality and cost effectiveness of medical care provided to patients by applying clinical acumen and using appropriate nationally recognized guidelines, criteria, and evidence based standards. Also assists UM management and Compliance team in preparation for audits and other regulatory activities as needed.
If you are licensed in California, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:
- Responsible for screening and reviewing prospective, concurrent, and retrospective referrals and authorizations for medical necessity and appropriateness of service and care and discussing with Medical Directors.
- Coordinate health care services with appropriate physicians, facilities, contracted providers, ancillary providers, allied health professionals, funding sources and community resources.
- Responsible for the prospective review to determine appropriateness of denial, possible alternative treatment, and draft denial language to ensure consistent application of standardized, nationally recognized UM criteria and appropriate use of denial language.
- Coordinate out-of-network and out-of-area cases with member, health plans and Case Management team.
- Review patient referrals within the specified care management policy timeframe (Type and Timeline Policy).
- Develop and maintain effective working relationships with physicians and office staff.
- Demonstrates a thorough understanding of the cost consequences resulting from care management decisions through utilization of appropriate reports such as Health Plan Eligibility and Benefits and Division of Responsibility (DOR).
- Maintains effective communication with the health plans, physicians, hospitals, extended care facilities, patients, and families.
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
- Graduation from an accredited Licensed Vocational Nurse program.
- Active, unrestricted LVN license in the state of California.
- 2+ years of clinical experience in an acute or ambulatory patient care setting including one year in a managed care environment such as a medical group, independent physician association, or health plan.
- Ability to work 8-5PM PST.
Preferred Qualifications:
- 3+ years of experience working as an LVN/LPN.
- 2+ years of care management, utilization review or discharge planning experience.
- Experience in an HMO or experience in a Managed Care setting.
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.
California Residents Only: The hourly range for this role is $19.47 to $38.08 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
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