Claims Auditor LVN

Description

JOB SUMMARY

The Claims Auditor LVN is responsible for retrospective review and audit of medical claims to ensure services billed are medically necessary, properly authorized, supported by medical documentation, and compliant with contract terms, regulatory requirements, and evidence-based clinical criteria. This role supports the Claims and Utilization Management departments by identifying billing discrepancies, overutilization trends, and opportunities for process improvement while maintaining strict confidentiality and regulatory compliance.

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Graduate of an accredited Licensed Vocational Nursing Program.

Preferred: Additional coursework or training in utilization management, case management, or healthcare compliance.

Experience 

Minimum: 2+ years of clinical LVN experience. 1+ years of utilization review, claims review, or managed care experience.

Preferred: Experience in claims auditing, Stop Loss review, or health plan operations.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Current State LVN License

Skills, Knowledge & Abilities

· Knowledge of medical terminology, clinical documentation standards, and nursing principles applicable to utilization review

· Working knowledge of Medicare, Medi-Cal, managed care regulations, and health plan rules

· Familiarity with clinical review criteria such as InterQual and/or Milliman/MCG

· Strong analytical, organizational, and documentation skills

· Ability to communicate clearly and professionally, both verbally and in writing

· Basic to intermediate computer skills and ability to work within claims and electronic medical record systems

· Ability to work independently in a fast-paced, deadline-driven environment

 PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This position is primarily office-based and requires the ability to sit for extended periods, perform frequent computer and phone work using hand and finger dexterity, and occasionally stand, walk, bend, reach, or lift light items (up to 10 pounds). The role involves multitasking, detailed analytical work, and the ability to perform effectively under routine deadlines and moderate stress.