Utilization Review Nurse - LVN

Responsibilities

• Own first-level reviews: Assess outpatient, ancillary, and inpatient pre-certification requests, including mental health, substance abuse, skilled nursing, and rehab stays, for medical appropriateness and necessity.
• Drive post-service reviews: Evaluate post-claim and post-service requests against clinical guidelines to confirm medical necessity after the fact.
• Escalate the right cases: Route denial authorizations to the Medical Director and, when required, through Independent Review Organizations (IRO), and refer out-of-guideline requests to advance review or senior care consultants.
• Cook up smooth discharges: Work directly with hospital staff to prepare patients for discharge and set up a clean transition to the next level of care.
• Manage the appeals process: Process appeals for non-certified services and complete non-certification letters accurately and on time.
• Redirect care in-network: Review plan documents for benefit determinations and steer providers and patients toward PPO options whenever possible.
• Connect patients to the right program: Identify and refer cases to case management, wellness, chronic disease, and Nurturing Together programs when clinical needs point that way.
• Document every review: Complete accurate, timely documentation in Eldorado/Episodes for every case, maintaining strict confidentiality throughout.
• Apply the right criteria: Use MCG guidelines, medical policies, Medscape, and NCCN to ground every determination in evidence-based standards.
• Hit the bar, every time: Meet daily productivity, quality, and turnaround-time standards, and support department operations and new initiatives as they roll out.

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 Word, Excel, PowerPoint, and Outlook
• Familiarity with MCG guidelines, NCCN criteria, and Medscape
• Experience documenting reviews in utilization management systems (e.g., Eldorado/Episodes)

Schedule

Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekends coverage as required.

Benefits

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• Paid Time Off—rest and recharge time is non-negotiable
• Mental health support, retirement planning, and financial protection
• Professional development with clear career progression and learning budgets
• Mission-driven culture where diverse perspectives drive real impact on people's health

Compensation

This position offers a base salary range of $25.00-$31.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.