Senior Utilization Management Nurse, LVN/LPN

This is a fully remote position, open to applicants in California.

📋 Description

• Perform timely concurrent evaluations of inpatient and skilled nursing services to assess medical necessity and appropriateness.

• Analyze clinical documentation for determining levels of care, treatment plans, and the justification for extended hospital stays.

• Ensure compliance with health plan policies, clinical standards, and regulatory requirements.

• Review and refer complex or borderline cases to the Medical Director.

• Prepare detailed clinical summaries for the Medical Director's assessment.

• Collaborate with the Medical Director on treatment recommendations and discrepancies in care.

• Process authorization requests for inpatient hospital, LTAC, inpatient rehabilitation, and skilled nursing admissions.

• Communicate with healthcare providers to gather necessary documentation and clarify treatment plans.

• Ensure prompt approvals or denials for requested services.

• Coordinate with case managers, social workers, and care teams regarding care transitions and discharge planning.

• Identify and escalate discharge obstacles and assist in transitions to outpatient or post-acute care.

• Maintain precise documentation of reviews, authorizations, denials, escalations, and Medical Director assessments.

• Contribute to quality improvement by monitoring utilization trends and identifying opportunities for resource optimization.

• Educate providers and staff on clinical guidelines, medical necessity standards, and authorization procedures.

• Stay updated on trends in utilization management, regulatory updates, and best practices.

• Participate in interdisciplinary team meetings and case conferences.

• Achieve performance metrics related to review timeliness, compliance, accuracy, escalation efficiency, utilization, and cost management.

⛳️ Requirements

• An active, unrestricted California nursing license is required for either a Registered Nurse (RN) or Licensed Vocational/Practical Nurse (LVN/LPN).

• A minimum of 4 years of clinical nursing experience is required, with at least 1 year in utilization review, case management, or a related field.

• Experience in a managed care environment with medical necessity evaluations is highly preferred.

• A Bachelor of Science in Nursing (BSN) is preferred.

• Preferred certifications include Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM).

• Strong understanding of clinical guidelines, including InterQual and MCG, as well as medical necessity criteria.

• Excellent analytical skills and attention to detail in the review of clinical documentation.

• Proficient in electronic health records (EHR), utilization management software, and the Microsoft Office Suite.

• Exceptional communication and interpersonal skills for collaboration with healthcare providers, payers, and members.

🏝️ Benefits

• An Equal Opportunity Employer dedicated to employing a diverse workforce.

• Preference for corporate office location; remote work may be considered.