Utilization Management Nurse, LVN/LPN

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

📋 Description

• Ability to conduct prospective, retrospective, or concurrent reviews of medical necessity for a designated group of members.

• Ability to assess cases for medical necessity and apply the relevant clinical criteria, including but not limited to Medicare, Medicaid/Medi-Cal, Interqual, Milliman, or specific guidelines from Health Plans.

• Ability to work in conjunction with the Medical Director to uphold the integrity of adverse determination notices according to the quality standards for such determinations.

• Ability to ensure that discharge planning is communicated in a timely and appropriate manner to transition of care teams, when necessary.

• Ability to meet or exceed established productivity targets.

• Ability to act as a resource for non-clinical team members when applicable.

• Complies with the Policies and Procedures established by the Quality Management Committee and performs any additional duties as required.

⛳️ Requirements

• Associate’s degree in Nursing is preferred.

• A minimum of 2 years of experience in clinical functions related to medical management.

• Familiarity with MCG, InterQual, and NCQA standards.

• Active and unrestricted California License as a Licensed Vocational Nurse (LVN).

• Managed Care Nursing Certification (CMCN) is preferred.

🏝️ Benefits

• Health benefits.

• Life and disability benefits.

• 401(k) savings plan with employer matching.

• Paid Time Off.

• Paid holidays.