[Hiring] Claims Review Nurse @Inland Empire Health Plan

Role Description

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.
• Identifying process improvements in the UM/Claims interface.
• Making recommendations to improve the claim authorization process and business rules between Claims and UM teams.
• Exercising independent judgment in conducting claims reviews.
• Supporting key clinical determinations in alignment with guidance from the Supervisor, Integrated Transitional Care.

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

Qualifications

• 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.

Requirements

• 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.
• Navigate 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; maintain ethical audit practices.
• Possess a strong attention to detail with the ability to multi-task.

Benefits

• 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.

Company Description

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

Work Model Location: Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership).

Pay Range: USD $63,897.60 - USD $83,075.20 /Yr.