Utilization Review Nurse - LVN

Job Summary

To support health plan administration, the full-time Utilization Review Nurse - LVN will conduct first-level clinical reviews for treatment requests, ensuring compliance and timely benefit determinations while working Monday to Friday with rotating Saturday coverage.

Key responsibilities

• Provide first-level review for outpatient pre-certification requests and inpatient hospital stays to determine medical necessity
• Refer cases for denial authorizations and assist hospital staff in preparing patients for discharge
• Document all reviews and maintain confidentiality while utilizing clinical guidelines and coding knowledge

Required qualifications

• Current LVN license in the United States or U.S. territory
• Minimum of 1 year of clinical experience
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding
• Proficiency in Microsoft Office applications
• Ability to convey complex information clearly and understand technical details