Medicare Clinical Operations Case Management Analyst LPN
22 hours ago
We are seeking a highly skilled LPN to join our team as a Clinical Operations Case Management Analyst. In this role, you will be responsible for collaborating with healthcare providers, members, and business partners to optimize member benefits, evaluate medical necessity, and promote effective use of resources.
Key Responsibilities- Conduct medical necessity reviews for inpatient admissions, outpatient services, surgical and diagnostic procedures, home health, durable medical equipment, and out-of-network services.
- Evaluate medical necessity and appropriateness of services in accordance with established policies and compliance guidelines.
- Provide notification of decisions in accordance with compliance guidelines.
- Coordinate with Medical Directors when services do not meet criteria or require additional review.
- Participate in staff meetings, regular trainings, and other collaborative meetings as appropriate.
- Work with management team to achieve operational objectives and financial goals.
- Support teams across the UM Department as needed.
- Active participation and completion of all required trainings.
- Maintain required licensures.
- Adhere to regulatory and departmental timeframes for review of requests.
- Meet/exceed department Turn Around time, daily established productivity goals, and service levels.
- Current unrestricted LPN/LVN license - Multi-State License Preferred.
- Minimum of 1 year experience in a regulated environment preferred.
- Minimum of 2+ years clinical experience.
- Strong customer orientation.
- Strong organizational, planning, and communication skills.
- Working knowledge of insurance industry, medical coding (CPT/HCPCS/ICD-10), and overall claims process a plus.
- Knowledge of National Coverage Determinations, Local Coverage Determinations, and MCG criteria are a plus.
We offer a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company-paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year, and paid holidays.
We are an equal opportunity employer and welcome applications from diverse candidates. If you require reasonable accommodation in completing the online application process, please email for support. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state, and local ordinances.
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