Claims Review Nurse, LVN (Remote)

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Reporting to the Supervisor, Integrated Transitional Care, the Claims Review Nurse, LVN is responsible for conducting timely medical reviews of IEHP facility and professional claims and appeals. The Claims Review Nurse, LVN identifies process improvements in the UM/Claims interface and makes recommendations to improve the claim authorization process and business rules between Claims and UM teams.  The Claims Review Nurse, LVN exercises independent judgment in conducting claims reviews and supports key clinical determinations in alignment with guidance from the Supervisor, Integrated Transitional Care.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

Education & Experience

• A minimum of one (1) year of relevant work experience
• Recent experience with inpatient and outpatient utilization and case management required
• Experience in auditing claims
  • Experience in reviewing inpatient medical records and claims preferred
  • Experience in managed care, MediCal, Medicare preferred
• High school diploma or GED
  • Associate’s degree in health care or a related field from an accredited institution
• Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required

Key Qualifications

• Knowledge and understanding of:
  • CPT, ICD-10, HCPCS and hospital revenue codes
  • Nationally recognized clinical criteria (e.g., InterQual, Milliman, Apollo)
  • Medi-Cal, Medicare and other state/federal Program & Regulations
  • Foundations of nursing practice and clinical pathways across inpatient, outpatient, and post‑acute settings
  • Health plan policies, prior authorization protocols, appeals processes, and denial management
  • Proficient in computer applications such as Word and Excel
  • Skilled in Data Entry
  • Skilled clinical review and judgement
  • Data analysis and trend identification skills
  • Communication skills (both written and verbal)
• Proven ability to:
  •  Exercise sound clinical judgement with minimal supervision
  • Escalate appropriately to Medical Director for complex determinations
  • Build trust and collaboration with physicians, nurses, ancillary staff, and claims personnel
  • Navigates diverse perspectives
  • Adjust to policy updates, workflow changes, and unusual circumstances while maintaining service quality
  • Handle PHI with strict adherence to privacy and security standards; maintains ethical audit practices
  • Possess a strong attention to detail with the ability to multi-task

Start your journey towards a thriving future with IEHP and apply TODAY!

Pay Range

• $63,897.60 USD Annually - $83,075.20 USD Annually