LVN Utilization Review Nurse

Job Summary

To support timely and accurate benefit determinations, the full-time LVN Utilization Review Nurse will conduct first-level clinical reviews of treatment requests, ensuring compliance with clinical guidelines while working Monday to Friday with occasional Saturday coverage.

Key responsibilities

• Provide first-level review for outpatient pre-certification requests and inpatient hospital stays to assess medical necessity
• Process appeals for non-certification of services and complete necessary documentation in compliance with established guidelines
• Collaborate with hospital staff to facilitate patient discharge and transition to the next level of care

Required qualifications

• Current LVN license in the United States or U.S. territory
• At least 1 year of clinical experience
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding
• Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook
• Familiarity with MCG guidelines and medical policies