CareMore LPN/LVN Utilization Review Sr
WellPoint - Cerritos, CA

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CareMore is looking for dynamic individuals to join our team! CareMore is a leading healthcare system specializing in providing a complete, pro-active health care experience to Senior Americans. CareMore strongly believes in our innovative and caring vision to lead the next generation of health care and we look for candidates that share in our passion. As a leader in senior healthcare for over 20 years, our vision is to significantly improve the lives of Medicare recipients by employing a dedicated staff of professionals who are passionate about changing lives. When you join CareMore, we’ll give you every opportunity to make a real difference. Be More with CareMore.

Responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and scripted algorithms within scope of licensure. This level works with the most complex elements and requires review of the most complex benefit plans. May also serve as mentor or preceptor for less experienced staff in addition to serving as department representative on various intradepartmental initiatives. May assist in formal training of associates and may be involved in process improvement initiatives within the utilization management function. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment. Primary duties may include, but are not limited to: Conducts pre-certification, inpatient, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract. Develops working partnerships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. Applies clinical knowledge to work with facilities and providers for care-coordination. May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process. Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications. Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.

Job Qualifications

Requires an LPN or LVN 2 years of clinical or utilization review experience; 2 years of managed care experience and knowledge of the medical management process; or any combination of education and experience, which would provide an equivalent background. Current unrestricted license or certification in applicable state(s) required.
Once an offer is accepted, all external applicants are subject to a background investigation
and if appropriate, drug testing. Offers of employment shall be contingent upon
passing both the background investigation and drug testing (if required).

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associate referral process on WorkNet. Official guidelines for the associate referral
program can be found in My HR.

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WellPoint, Inc. (WellPoint) is a health benefits company serving 35 million medical members, as of December 31, 2008. The Company is an...