Reporting to the Supervisor, Integrated Transitional Care, the Claims Review Nurse, LVN is responsible for timely medical reviews of facility and professional claims and appeals. This role serves as a clinical interface between Claims and Medical Services, identifies process improvements, supports authorization decisions, and helps ensure claims are reviewed in alignment with departmental policies and regulatory requirements.
The position also reviews inpatient and outpatient claims, evaluates medical records and billing practices, tracks trends, and provides reports and recommendations to leadership.
Education and experience
- Minimum of 1 year of relevant work experience
- Recent experience with inpatient and outpatient utilization and case management required
- Experience in auditing claims required
- Experience reviewing inpatient medical records and claims preferred
- Experience in managed care, Medi-Cal, or Medicare preferred
- High school diploma or GED required
- Associate degree in health care or a related field from an accredited institution preferred
- Active, unrestricted California LVN license required
Knowledge and skills
- Knowledge of CPT, ICD-10, HCPCS, and hospital revenue codes
- Familiarity with nationally recognized clinical criteria such as InterQual, Milliman, or Apollo
- Understanding of Medi-Cal, Medicare, and other state/federal program regulations
- Knowledge of nursing practice and clinical pathways across inpatient, outpatient, and post-acute settings
- Understanding of prior authorization protocols, appeals processes, and denial management
- Proficiency with Word and Excel
- Strong data entry, clinical review, judgment, data analysis, and trend identification skills
- Strong written and verbal communication skills
- Ability to exercise sound clinical judgment with minimal supervision
- Ability to escalate complex determinations to the Medical Director appropriately
- Strong attention to detail and ability to multitask
Benefits and perks
- Competitive salary
- On-site fitness center
- Medical, dental, and vision insurance
- Life, short-term, and long-term disability options
- Career advancement opportunities and professional development
- Wellness programs supporting work-life balance
- Flexible Spending Account for health care and childcare
- CalPERS retirement
- 457(b) option with contribution match
- Paid life insurance for employees
- Pet care insurance
Location
California, US
Employment Type
Full-time
Experience Level
Associate
Salary Range
$63,898 - $83,075
Remote work allowed
Yes
Posted
1 month ago