LVN Utilization Review Nurse

Job Summary

To support patient care, the full-time LVN Utilization Review Nurse will manage pre-certification and post-service reviews, ensure accurate documentation, and coordinate discharges while working Monday through Friday with occasional Saturday coverage.

Key responsibilities

• Own first-level reviews for outpatient, ancillary, and inpatient pre-certification requests, assessing medical appropriateness and necessity
• Drive post-service reviews to confirm medical necessity against clinical guidelines
• Manage the appeals process for non-certified services and ensure timely documentation in utilization management systems

Required qualifications

• Current LVN license in the United States or a U.S. territory
• 1+ years of clinical experience
• Working knowledge of medical claims and ICD-10, CPT, and HCPCS coding
• Proficiency with Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)
• Familiarity with MCG guidelines, NCCN criteria, and Medscape