An independent subsidiary of WellPoint, Inc, National Government Services (NGS) is one of the largest Medicare contractors in the country, serving nearly 200,000 providers and suppliers and over 20 million customers with Medicare in 20 states and five U.S. territories.
Bring your expertise to our innovative, achievement-driven culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.
Our LPN/LVN Utilization Review will work 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. 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, concurrent (if not associated with CM or DM triage), retrospective, 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 relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. 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.
Requires a minimum of an LPN or LVN with current licensure or certification in the appropriate state and 2 years clinical experience, recent utilization review experience or any combination of education and experience, which would provide an equivalent background. Knowledge of the medical management process preferred. Requires strong oral and written communication skills, effective problem-solving and facilitation skills, and PC experience including Microsoft Word required. Medicare Appeals experience a plus.
WellPoint is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2012 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at
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