Overview Join to apply for the LVN Utilization Review Representative, Inpatient Review (Part Time) role at CHOC Children's.
Work Location: Orange, California. Work Shift: Day – 08hrs (United States of America).
Job Summary The qualified candidate will have direct experience performing inpatient reviews, using MCG or InterQual criteria. The Utilization Review Representative is responsible for utilization review of all inpatient and outpatient statuses. This role processes internal and external authorization requests with payors for treatments, services, and supplies in collaboration with the RN Care Managers (Inpatient and Outpatient). It will assist in the completion of the RN Care Manager’s caseload as assigned, supporting data collection, insurance verification, financial counseling and customer service. The work produced should be accurate and complete in all areas of responsibilities. This is a part-time position, 3–4 days per week (scheduled days fall Monday–Friday, 8–5).
Responsibilities Perform inpatient reviews using criteria such as MCG or InterQual.
Perform utilization review of inpatient and outpatient statuses.
Process internal and external authorization requests with payors for treatments, services, and supplies in collaboration with RN Care Managers.
Assist in completing the RN Care Manager’s caseload; collect data, verify insurance, provide financial counseling, and deliver customer service.
Ensure work is accurate and complete across all responsibilities.
Experience Required: 2 years of acute care or ambulatory care experience.
Preferred: Over one year of nursing experience in an acute care or ambulatory setting; one or more years of pediatric nursing experience and prior experience as a Utilization Review nurse.
Education Required: Graduate of an accredited Licensed Vocational Nursing program.
Preferred: Bachelor’s Degree in Nursing from an accredited university.
Training and Certifications Required: None required.
Preferred: Certification in Utilization Review and/or Case Management; CPN.
Specialized Skills Required: Ability to work under pressure with changing priorities; excellent interpersonal communication; conflict resolution, problem solving and negotiation skills; clinical knowledge across age groups, medical conditions, and treatment plans; strong organizational and time management skills; ability to multitask and prioritize; ability to work independently and exercise sound judgment; ability to communicate with third-party payers to obtain authorization; able to fulfill required competencies after orientation and maintain annual department competency requirements; ability to work collaboratively across diverse backgrounds; computer skills in Microsoft Office.
Preferred: Knowledge of CCS/Medi-Cal regulations; knowledge of third-party payor requirements to optimize reimbursement; ability to apply severity of illness or intensity of service criteria to information from clinical documentation; knowledge of third-party payor methods; bilingual.
Licensure Required: Licensed Vocational Nurse – CA (LVN), Basic Life Support (BLS).
Preferred: Ped ER Assess, Recog & Stabilization (PEARS); Comprehensive Crisis Management (CCM); Certified Pediatric Nurse (CPN).
Work Environments and Physical Requirements Work environment: Light to moderate energy level; lifting and carrying up to 25–35 lbs; push/pull up to 50–100 lbs.
Physical Activity Requirements include bending, carrying, climbing, keyboard use, pinching/fine motor activities, pushing/pulling, reaching, sitting, standing, and other movements as necessary.
Non-Discrimination Statement: CHOC does not discriminate on the basis of age, race, color, religion, national origin, ancestry, marital status, genetic information, disability, sex, gender (including pregnancy, breastfeeding, childbirth, lactation or related medical conditions), gender identity or expression, medical condition, sexual orientation, veteran status, military or uniformed service member status, or other protected characteristics in accordance with state and federal laws. CHOC will consider for employment qualified applicants with criminal histories, in accordance with the Fair Chance Initiative for Hiring. We encourage individuals from all backgrounds to apply for positions at CHOC, even if your experience doesn’t align perfectly with the listed qualifications for a particular role, as your unique experience may be a great addition to our culture for another one of our opportunities. If you desire support or accommodations throughout the Talent Acquisition process, please inform your Talent Acquisition Partner.
Seniority level: Entry level
Employment type: Part-time
Job function: Health Care Provider
Industries: Hospitals and Health Care
Note: This posting includes multiple related job titles for CHOC and is intended to reflect the available opportunity.