Utilization Review Nurse – LVN

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

📋 Description

• Take charge of initial reviews: Evaluate outpatient, ancillary, and inpatient pre-certification requests, which include mental health, substance abuse, skilled nursing, and rehabilitation stays, ensuring their medical appropriateness and necessity.

• Facilitate post-service evaluations: Assess post-claim and post-service requests against clinical guidelines to verify medical necessity retrospectively.

• Identify cases for escalation: Direct denial authorizations to the Medical Director and, when necessary, through Independent Review Organizations (IRO), and refer out-of-guideline requests for advanced review or senior care consultation.

• Ensure seamless discharges: Collaborate with hospital personnel to prepare patients for discharge and establish a smooth transition to the subsequent level of care.

• Oversee the appeals procedure: Handle appeals for non-certified services and ensure non-certification letters are completed accurately and punctually.

• Guide in-network care: Analyze plan documents for benefit decisions and encourage providers and patients to opt for PPO options whenever feasible.

• Link patients with appropriate programs: Recognize and refer cases to case management, wellness, chronic disease, and Nurturing Together programs when clinical needs indicate such actions.

• Maintain comprehensive documentation: Ensure accurate and timely documentation in Eldorado/Episodes for each case, upholding strict confidentiality at all times.

• Implement appropriate criteria: Utilize MCG guidelines, medical policies, Medscape, and NCCN to base every decision on evidence-based standards.

• Consistently meet performance standards: Achieve daily productivity, quality, and turnaround-time benchmarks, while supporting departmental operations and new initiatives as they develop.

⛳️ Requirements

• Valid LVN license in the United States or a U.S. territory

• Over 1 year of clinical experience

• Familiarity with medical claims and ICD-10, CPT, and HCPCS coding

• Competence in Microsoft Word, Excel, PowerPoint, and Outlook

• Knowledge of MCG guidelines, NCCN criteria, and Medscape

• Experience with documenting reviews in utilization management systems (e.g., Eldorado/Episodes)

🏝️ Benefits

• Competitive base salary and benefits starting on day one

• Comprehensive medical and dental coverage through our own health solutions (yes, we utilize what we create)

• Paid Time Off—time to rest and recharge is essential

• Support for mental health, retirement planning, and financial security

• Opportunities for professional growth with clear career advancement and learning budgets

• A mission-driven culture where diverse viewpoints create a significant impact on individuals' health