Responsibilities

The Utilization Review Specialist (LVN) is responsible for conducting medical reviews, benefit verification, and applying criteria to determine medical necessity for health care services requiring authorization prior to services being rendered for members.  The Utilization Review Specialist (LVN) serves as a liaison in reviewing requests for medical and surgical procedures, services and admissions. The Utilization Review Specialist communicates with providers regarding pertinent information needed for medical review to ensure service decisions are determined within appropriate timeframes. This position will serve as a liaison to the Grievance and Appeals Department for Medicare Advantage appeals. 

The Utilization Review Specialist (LVN) is responsible for completion and review of denial letters based on Texas Department of Insurance (TDI) and or Centers for Medicare and Medicaid (CMS) and healthplan requirements.  The Utilization Review Specialist (LVN) will serve as liaison and primary point of contact for add on procedures performed at the KS Ambulatory surgery center (ASC). The Utilization Review Specialist (LVN) will support the Utilization Review quality assurance initiatives including mock audits to ensure compliance.  The Utilization Review Specialist will be flexible and adapt to changes in polices and procedures, new techniques, and additional responsibilities as assigned to meet changing business needs

 

Job Title: Utilization Review Specialist (LVN)

Location: Pearland Administrative Office, Main Campus

Department: Utilization Management

Job Type: Full Time 

Salary Range: $59,108 - $73,025 (Pay is based on several factors including but not limited to education, work experience, certifications, etc.)

 

Qualifications

Education

Required: Licensed Vocational Nurse; CEU requirement

Preferred: Certification in area of specialization

Experience

Required: 5 years utilization review experience at a health plan, ACO, IPA, or provider group or 3 years clinical 

 

nursing experience

Preferred: N/A

License(s)

Required: TX LVN license, Valid Driver’s license

Preferred: N/A

Special Skills

Required: Excellent verbal and communication skills, and organizational skills

Preferred: N/A

Other 

Required: Experience working with insurance (HMO, PPO, and POS) companies to obtain authorizations and 

 

pre-certification for medical services. 

 

Ability to work from designated office for collaborative / interactive fulfilment of duties; ability to concentrate 

 

in an open-office cubicle environment; interact with other staff members and / or outside associates; perform 

 

telephone and / or computer work for extended periods of time; operate office equipment such as a 

 

computer, telephone, and copy / scan / fax machine; actively participate in department meetings via phone, 

 

computer or in person. 

 

Consistent and prompt attendance at employer worksite is an essential job requirement.

Preferred: Bilingual

 

Working Environment: Office

 

About Us

Start your career journey and become a part of a community of renowned Healthcare professionals.  Kelsey-Seybold Clinic is Houston’s fastest growing, multispecialty organization with more than 40 premier locations and over 65 specialties.  Our clinics are comprised of more than 600 physicians and as we continue to grow, our focus is providing quality patient care by adding to our team of clinical and non-clinical professionals that work together in a convenient, coordinated, and collaborative manner.  Enjoy the rewards of a successful career while maintaining a work/life balance by joining our team today and changing the way health cares. 

 

Why Kelsey-Seybold Clinic?

Medical, Vision, and Dental Tuition Reimbursement Company Matching 401K Employee Reward and Recognition Program Paid time off for vacation, sick, and holidays Employee Assistance Program Continuing Medical Education allowance