Utilization Management Nurse, LVN/LPN

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

📋 Description

• Conduct timely concurrent evaluations of inpatient and skilled nursing services to assess medical necessity and appropriateness using clinical guidelines such as InterQual and MCG.

• Review clinical documentation for level-of-care assessments, treatment plans, and ongoing hospital stays.

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

• Refer complex or borderline cases to the Medical Director and provide detailed clinical summaries.

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

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

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

• Ensure prompt approvals or denials and escalate cases when necessary.

• Coordinate with case managers, social workers, and care teams to facilitate transitions in care.

• Engage in interdisciplinary discussions and identify barriers to discharge.

• Assist with transitions from inpatient to outpatient or post-acute care settings.

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

• Support quality improvement initiatives by tracking utilization trends and identifying opportunities for resource optimization.

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

• Stay informed about trends in utilization management, regulatory updates, and best practices.

• Participate in interdisciplinary team meetings and case conferences.

• Meet performance metrics concerning review timeliness, compliance, accuracy, escalation efficiency, utilization, and cost management.

⛳️ Requirements

• Registered Nurse (RN) or Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license is required.

• Minimum of 2-3 years of clinical nursing experience, including at least 1 year in utilization review, case management, or a related field.

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

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

• Additional clinical nursing or case management certifications are advantageous.

• Strong understanding of clinical guidelines (e.g., InterQual, MCG) and medical necessity criteria.

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

• Strong analytical skills and meticulous attention to detail when reviewing clinical documentation.

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

🏝️ Benefits

• Health benefits.

• Life and disability benefits.

• 401(k) savings plan with matching contributions.

• Paid Time Off.

• Paid holidays.