Utilization Management Nurse, LPN
Point C is a National third-party administrator (TPA) with local market presence that delivers customized self-funded benefit programs. Our commitment and partnership means thinking beyond the typical solutions in the market – to do more for clients – and take them beyond the standard “Point A to Point B.” We have researched the most effective cost containment strategies and are driving down the cost of plans with innovative solutions such as, network and payment integrity, pharmacy benefits and care management. There are many companies with a mission. We are a mission with a company.
The Utilization Management Nurse is responsible for handling authorization requests, reviewing requests for medical necessity and plan coverage, managing provider communications, and ensuring accurate data entry of coding and provider information. This position requires knowledge of clinical terminology, basic nursing, attention to detail, and the ability to manage multiple tasks in a fast-paced environment.
Primary Responsibilities:
- Input medical coding and provider information for authorization requests.
- Review and ensure completeness and accuracy of authorization requests and medical records.
- Review submitted medical records and clinical guidelines to ensure medical necessity requirements are met.
- Escalate any requests that require physician review for further research or denial.
- Coordinate with Case Management team as needed.
- Knowledge of URAC standards related to the comprehensive performance of duties.
Required Qualifications:
- Current unrestricted LPN or RN licensure.
- Experience with medical billing, utilization management, or managed care.
- Knowledge of medical coding, authorization processes, and healthcare terminology.
- Strong communication and customer service skills.
- Attention to detail and accuracy in data entry.
- Critical thinking and time management skills.
- Proficient in Microsoft Word, Excel, PowerPoint, and Outlook.
- Legally authorized to work in the United States.
Individual compensation will be commensurate with the candidate's experience and qualifications. Certain roles may be eligible for additional compensation, including bonuses, and merit increases. Additionally, certain roles have the opportunity to receive sales commissions that are based on the terms of the sales commission plan applicable to the role.
Pay Transparency
$61,000 - $63,000 USD
- Comprehensive medical, dental, vision, and life insurance coverage
- 401(k) retirement plan with employer match
- Health Savings Account (HSA) & Flexible Spending Accounts (FSAs)
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Paid time off (PTO) and disability leave
- Employee Assistance Program (EAP)
Equal Employment Opportunity: At Point C Health, we know we are better together. We value, respect, and protect the uniqueness each of us brings. Innovation flourishes by including all voices and makes our business—and our society—stronger. Point C Health is an equal opportunity employer and we are committed to providing equal opportunity in all of our employment practices, including selection, hiring, performance management, promotion, transfer, compensation, benefits, education, training, social, and recreational activities to all persons regardless of race, religious creed, color, national origin, ancestry, physical disability, mental disability, genetic information, pregnancy, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, and military and veteran status, or any other protected status protected by local, state or federal law.
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