CEI · 1 day ago
LPN - Medical Claims Reviewer (Remote)
United States
Full-time
Remote
Entry, Mid Level
2+ years expCEI is a trusted technology partner delivering solutions to transform businesses. They are seeking a Medical Claims Reviewer responsible for performing medical reviews and utilization management for various benefits and services, including reviewing clinical documentation and supporting medical claims review activities.
Information TechnologyIT ManagementMechanical EngineeringSoftware
Responsibilities
Performs medical claim reviews and makes a reasonable charge payment determination
Monitors process’s timeliness in accordance with contractor standards
Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines
Utilizes allocated resources to back up review determination
Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process
May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs
Performs screenings/assessments and determines risk via telephone
Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services
Provides education to members and their families/caregivers
Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each
Conducts research necessary to make thorough/accurate basis for each determination made
Participates in quality control activities in support of the corporate and team-based objectives
Participates in all required training
Qualification
Required
Must have more than 2 years of nursing experience
Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR
Active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR
Active, unrestricted LBSW licensure from the United States and in the state of hire
Easily adapts to change in workload
Team works well together and is willing to help each other
Must be a local candidate
Typical day will be reviewing clinicals for pre-certifications for durable medical equipment, home health care, and elective procedures
Must be able to come onsite as needed for meetings and training
Bachelor's degree in Social Work, OR
Graduate of an accredited school of licensed practical nursing or licensed vocational nursing
Preferred
Associate degree in nursing, OR
Graduate of an accredited school of nursing
Active, unrestricted RN licensure from the United States and in the state of hire, OR
Active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
Company
CEI
CEI is at the forefront of providing software solutions for pressure vessel design and welding procedure management, being the first company to offer a solution for ASME Section VIII and Section IX over 30 years ago.
11-50 employees
Funding
Current Stage
Early StageLeadership Team
Michael Hartnett
CEO
Amee Hamilton
Chief Technology Officer
Company data provided by crunchbase