Utilization Review Nurse-LVN/LPN

Responsibilities
Utilization Review Nurse (LVN)
The Utilization Review Nurse conducts first-level clinical reviews to determine the medical necessity and appropriateness of treatment requests, working under the supervision of a Registered Nurse. This role supports timely, accurate benefit determinations across outpatient, inpatient, and post-service claims while ensuring compliance with clinical guidelines and regulatory standards.

Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required.

What You'll Actually Do

Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity; and all post claim or post service reviews.
Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO).
Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.
Refer requests that fall outside of established guidelines to advance review or senior care consultants.
Process appeals for non-certification of services; complete non-certification letters when appropriate.
Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers.
Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together program.
Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality.
Utilize MCG guidelines, medical policies, Medscape, and NCCN.
Ability to meet productivity, quality, and turnaround times daily.
Assists with department operations and implementations

Qualifications
What You Bring to Our Team

Education and Experience:

Current LVN license in the United States or U.S. territory.
1+ years of clinical experience required.

Required Knowledge, Skills, and Abilities:

Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook
Excellent verbal and written communication skills
Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others