Utilization Review Nurse - LVN

Job Summary

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

Key responsibilities

• Provide first-level reviews for outpatient and inpatient pre-certification requests, ensuring medical necessity and appropriateness
• Process appeals for non-certification of services and complete necessary documentation in compliance with guidelines
• Collaborate with hospital staff to facilitate patient discharge and smooth transitions 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 required
• Knowledge of medical claims and coding (ICD-10, CPT, HCPCS)
• Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook
• Ability to communicate complex information clearly and effectively