Central Denials UM LVN - Remote CA

About the position The position is responsible for ensuring the integrity of the adverse determination processes and the accuracy of clinical decision-making related to the application of criteria and compliant denial notices. The role involves working with a focus on health equity, affordability, quality, and convenience in health care, particularly within the Optum Pacific West region, which serves over 2.5 million patients. Responsibilities • Exhibit behavior and communication skills that demonstrate Optum's commitment to superior customer service. • Perform all functions of the UM nurse reviewer. • Compose denial letters in compliance with federal and state regulations, health plan requirements, and NCQA standards. • Construct denial notices that are understandable to the intended recipients. • Ensure denial reasons are appropriate and easily understandable. • Provide appropriate references for benefits, guidelines, criteria, or protocols based on the type of denial. • Select and apply the correct level of hierarchy based on available medical information. • Provide relevant clinical information for decision-making. • Document communications with the requesting provider regarding clinical information related to the criteria applied. • Evaluate out-of-network and tertiary denials for accessibility within the network. • Perform quality assurance audits on each denial prior to finalization. • Consult with the medical director on cases that do not meet established guidelines. • Escalate non-compliant cases to UM compliance and report on denial activities. • Collaborate with UM compliance for quality improvement efforts. • Identify gaps in training or processes impacting compliance and communicate solutions in writing. • Meet or exceed productivity targets. • Protect and disclose patients' protected health information (PHI) in accordance with HIPAA standards. Requirements • Graduation from an accredited Licensed Vocational Nurse program. • Current LVN license in California. • 1+ years of experience as an UM nurse reviewer. • 1+ years of recent clinical experience working as an LVN/LPN. Nice-to-haves • Bachelor's degree in Nursing. • 3+ years of managed care utilization experience. • 1+ years of experience performing essential functions of a CDU nurse. Benefits • Comprehensive benefits package. • Incentive and recognition programs. • Equity stock purchase. • 401k contribution.