What are the responsibilities and job description for the Medical Review Nurse (LPN) position at OpTech LLC?
Why work at OpTech? OpTech is a woman-owned company that values your ideas, encourages your growth, and always has your back. When you work at OpTech, not only do you get health and dental benefits on the first day of employment, but you also have training opportunities, flexible / remote work options, growth opportunities, 401K and competitive pay. Apply today! OpTech is an EOE, all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. https : / / www.optechus.com / eeo_self_identification /
JOB SUMMARY
The Medical Review Nurse LPN reviews, authorizes, coordinates, and responds to requests for services for members. This position also communicates telephonically with providers and their offices, and occasionally with members. Makes decisions based on established policies and procedures, medical coverage guidelines, benefits, InterQual criteria, nursing knowledge. Refers cases to medical directors for potential denial.
Essential Functions
- Review and authorize, as appropriate, phone / fax referral / authorization and clinical form requests per established criteria meeting compliance standards and timeframes
- Review all requests not approved by the non-clinical support rep to determine benefit coverage and medical necessity
- Review cases and potential denials with the Medical Directors
- Research requests not clearly meeting established criteria
- Assist the Prior Authorization non-clinical reps with the Prior Authorization process
- Coordinate and maintain complete written documentation on all prior authorization's requests.
- Collaborate with other departments, such as Claims, UM, Quality, Disputes / Appeals, and other external vendors.
- Log into phone queue to service providers
- Answer inbound calls regarding authorizations within established time frame
- Document contact information in electronic medical record system
- Maintain productivity
- Handle calls professionally
- Provide accurate prior authorization information to provider offices
Job Requirements
Required Experience :
0-2 years related work experience
Required Education :
High school Diploma or GED
Required Licenses and Certifications
RN - Licensed Practical Nurse - State Licensure
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