Utilization Review Nurse I – LVN/LPN

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

📋 Description

• Assess requests for medical necessity, appropriate care levels, documentation completeness, and benefit coverage.

• Examine outpatient and ancillary pre-certification and prior authorization requests.

• Analyze inpatient stays, including behavioral health, substance use, skilled nursing, and rehabilitation services.

• Conduct post-service or post-claim reviews as designated.

• Implement internal medical policies, group-specific protocols, NCCN, and MCG guidelines.

• Document criteria and policy rationale within the utilization management system.

• Escalate cases that fall outside guidelines, do not meet criteria, or may require adverse determination to senior staff or the Medical Director.

• Assist with IRO referrals in accordance with policy and jurisdictional requirements.

• Examine plan documents to facilitate benefit determinations.

• Guide providers and members towards PPO or in-network options when suitable.

• Compile comprehensive case summaries for Medical Director review, encompassing adverse determinations and IRO referral pathways.

• Achieve productivity, quality, and turnaround goals.

• Engage in quality initiatives such as inter-rater reliability assessments (IRRA).

• Utilize feedback to ensure audit readiness for URAC, NCQA, and other relevant standards.

• Safeguard member privacy and adhere to HIPAA and minimum necessary standards.

• Support team operations and uphold service-level commitments.

• Contribute to staff training as needed.

⛳️ Requirements

• Graduate from an accredited nursing program (LVN/LPN).

• Hold a current, unrestricted U.S. or U.S. territory nursing license; compact license acceptable where applicable.

• Possess a minimum of 1-2 years of recent clinical experience in acute care, med-surg, ICU/ED, or a related setting.

• Prior experience in utilization review or utilization management is preferred.

• Ability to interpret medical records and apply evidence-based criteria and medical policies.

• Familiarity with MCG and NCCN clinical guidelines and UM documentation systems.

• Proficient in Microsoft Word, Excel, Outlook, and Teams.

• Capability to learn additional tools as required.

• Comfortable working across multiple screens and using a headset-based phone system.

• Strong typing skills and accurate data entry abilities.

• Competent in using remote-work technology such as VPN and departmental platforms like SharePoint/Drives in compliance with security policies.

• Adherence to HIPAA and minimum necessary standards compliance.

• Completion of required annual training and testing in a timely manner.

🏝️ Benefits

• Competitive base salary.

• Benefits effective from day one.

• Comprehensive medical and dental coverage.

• Paid Time Off.

• Mental health support.

• Retirement planning.

• Financial protection.

• Opportunities for professional development.

• Clear career advancement pathways.

• Learning budgets.

• Wellness programs.

• Additional employee perks.

• Mission-driven culture where diverse perspectives create real impact.