LPN Care Review Clinician I (68301)

Company: Professional Management Enterprises
Location: New York
Posted on: March 13, 2025

Job Description:

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

Keywords: Professional Management Enterprises, New York , LPN Care Review Clinician I (68301), Healthcare , New York, New York