California Licensed Utilization Review Nurse

Job Summary

To support a growing healthcare practice, the remote Senior Utilization Management Nurse, LVN/LPN will conduct real-time clinical reviews to ensure the medical necessity and appropriateness of healthcare services, collaborating with healthcare providers and the Medical Director while managing authorization requests and compliance documentation.

Key Responsibilities

• Conduct timely concurrent reviews of inpatient and skilled nursing services to assess medical necessity based on clinical guidelines
• Collaborate with the Medical Director on complex cases, providing clinical summaries and treatment recommendations
• Process authorization requests and communicate with providers to ensure timely approvals or denials of services

Required Qualifications

• Active, unrestricted California nursing license as a Registered Nurse (RN) or Licensed Vocational/Practical Nurse (LVN/LPN); BSN preferred
• Minimum of 4 years of clinical nursing experience, with at least 1 year in utilization review or case management
• Preferred certifications include Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM)
• Strong knowledge of clinical guidelines such as InterQual and MCG
• Proficiency in electronic health records (EHR) and utilization management software