LPN Care Review Clinician I (68301)
 Professional Management Enterprises | |
 United States, New York, New York | |
 Mar 12, 2025 | |
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Job Description: All UM standard/ expedited Inpatient, Outpatient and Custodial Care clinical reviews for MLTC members. MUST be a NY State License Practical Nurse (LPN). This position is FULLY REMOTE. Schedule M-F 8:30am-5:00pm EST. Must Have Skills: Must have experience in UM, experience with Turnaround Timeframes, good with computer systems and be able to learn a new system, have done clinical reviews and processed denials and partial denial determinations, know MCG and can use it, case presentation for medical reviews, know Medicaid/ Medicare guidelines. Bi-lingual in any language is preferred but not mandatory Day to Day Responsibilities: All UM standard Inpatient, Outpatient and Custodial Care processes and workflows for any requests, verbal notifications for denials/partial denials to both member and provider, participation in IDTs, personal queue management and clinical reviews, meeting expected productivity and performance Productivity expectations are set a by Enterprise Clinical Services based on the local HP time studied performance. Standard full capacity and performance reviews expectations is 30 cases a day. Required Years of Experience: At least 1-2 years' experience in UM. Required Licensure / Education: Licensure required is a NY State License Practical Nurse -LPN NY Job Description: All UM standard/ expedited Inpatient, Outpatient and Custodial Care clinical reviews for MLTC members. MUST be a NY State License Practical Nurse (LPN). This position is FULLY REMOTE. Schedule M-F 8:30am-5:00pm EST. Must Have Skills: Must have experience in UM, experience with Turnaround Timeframes, good with computer systems and be able to learn a new system, have done clinical reviews and processed denials and partial denial determinations, know MCG and can use it, case presentation for medical reviews, know Medicaid/ Medicare guidelines. Bi-lingual in any language is preferred but not mandatory Day to Day Responsibilities: All UM standard Inpatient, Outpatient and Custodial Care processes and workflows for any requests, verbal notifications for denials/partial denials to both member and provider, participation in IDTs, personal queue management and clinical reviews, meeting expected productivity and performance Productivity expectations are set a by Enterprise Clinical Services based on the local HP time studied performance. Standard full capacity and performance reviews expectations is 30 cases a day. Required Years of Experience: At least 1-2 years' experience in UM. Required Licensure / Education: Licensure required is a NY State License Practical Nurse -LPN NY | |