Utilization Management Nurse, LVN/LPN

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

📋 Description

• Evaluate and manage prior authorization requests according to clinical guidelines, including Medicare, Medicaid/Medi-Cal criteria, MCG, or specific health plan protocols.

• Assess the medical necessity and appropriateness of requested services.

• Verify patient eligibility, benefits, and coverage information.

• Serve as a liaison among healthcare providers, patients, and health plans.

• Communicate authorization decisions in a timely manner.

• Clarify denials or suggest alternative solutions while collaborating with Medical Directors on adverse determinations.

• Ensure adherence to regulatory requirements concerning adverse determination notifications.

• Document authorization activities within electronic medical records or authorization systems.

• Maintain compliance with federal, state, and health plan regulations.

• Stay informed about changes in policy and clinical criteria.

• Identify trends in authorization denials and propose enhancements to processes.

• Participate in team meetings, training sessions, and audits.

⛳️ Requirements

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

• A 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.

• Strong analytical and critical thinking abilities.

• Proficient in medical terminology and pharmacology.

• Excellent written and verbal communication skills.

• Capable of working independently and collaboratively in a dynamic setting.

• Adaptable and self-motivated.

• Familiarity with EMR systems and prior authorization platforms.

• Proficient in Microsoft Office Suite (Word, Excel, Outlook).

🏝️ Benefits

• Health benefits.

• Life and disability benefits.

• 401(k) savings plan with matching contributions.

• Paid Time Off.

• Paid holidays.