Utilization Review Nurse LVN

Job Summary

To ensure timely and accurate care decisions, the full-time Utilization Review Nurse LVN/LPN will perform clinical reviews for medical necessity and benefit coverage, applying clinical guidelines and maintaining compliance in a remote work environment.

Key responsibilities

• Evaluate requests for medical necessity and appropriate level of care to ensure compliance and timely decisions
• Conduct first-level reviews across various care settings, including outpatient and inpatient requests
• Document decisions and escalate complex cases to senior staff or the Medical Director as needed

Required qualifications

• Graduate of an accredited nursing program (LVN/LPN)
• Current, unrestricted U.S. or U.S. territory nursing license
• Minimum 1-2 years of recent clinical experience in acute care or relevant settings
• Prior experience in utilization review or utilization management preferred
• Ability to interpret medical records and apply evidence-based criteria