Care Review Clinician (LVN) - MUST RESIDE IN TEXAS

Job description

JOB DESCRIPTION: Fully remote opportunity for a TX licensed LVN with Utilization Management experience to join our Prior Authorization reviewing team. Previous UM experience with MCG/Interqual guidelines as well as working within UM in an MCO is highly preferred, but we will also consider UM experience within a hospital as well. Schedule is Monday – Friday, 9 AM – 6 PM CST. This position is with our Texas Health Plan, and these reviews will be for our Medicaid Members in Texas. Reviews will include, but are not limited to, doctor appointments, outpatient services, DME. Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, Teams, and One Note. Job Summary: Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties: - Assesses services for members to ensure optimum outcomes, cost-ef...