Utilization Review Nurse – LVN/LPN

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

📋 Description

• Conduct initial assessments for all outpatient and ancillary pre-certification requests to evaluate medical appropriateness.

• Review all inpatient hospital stays, including mental health, substance abuse, skilled nursing, and rehabilitation, for medical necessity.

• Ensure appropriate referrals to the medical director for authorization denials through independent review organizations (IRO).

• Collaborate with hospital personnel to prepare patients for discharge, facilitating a seamless transition to the next level of care.

• Direct requests that do not align with established guidelines to advance review or senior care consultants.

• Manage appeals for service non-certification and draft non-certification letters when necessary.

• Review plan documents for benefit determinations, striving to redirect providers and patients to PPO providers.

• Identify and refer potential cases to case management, wellness initiatives, chronic disease management, and the Nurturing Together program.

• Complete all review documentation in Eldorado/Episodes while maintaining confidentiality.

• Utilize MCG guidelines, medical policies, Medscape, and NCCN for reference.

• Demonstrate the ability to meet daily productivity, quality, and turnaround time targets.

⛳️ Requirements

• Must possess a current LVN license in the United States or a U.S. territory.

• A minimum of 1 year of clinical experience is required.

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

• Proficient in software applications, including but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint, and Outlook.

• Exceptional verbal and written communication abilities.

• Capable of articulating complex or technical information clearly and understanding intricate information from others.

🏝️ Benefits

• Competitive base salary and benefits starting from day one.

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

• Paid Time Off—time for rest and rejuvenation is a priority.

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

• Opportunities for professional development with clear pathways for career advancement and dedicated learning budgets.

• A mission-driven culture where diverse perspectives contribute to meaningful impacts on people's health.