Utilization Review Nurse-LVN/LPN

Responsibilities

• Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness;
• All inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity;
• All post claim or post service reviews.
• Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO).
• Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.
• Refer requests that fall outside of established guidelines to advance review or senior care consultants.
• Process appeals for non-certification of services; complete non-certification letters when appropriate.
• Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers.
• Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together program.
• Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality.
• Utilize MCG guidelines, medical policies, Medscape, and NCCN.
• Able to meet productivity, quality, and turnaround times daily.
• Assists with department operations and implementations

Qualifications

• Current LVN license in the United States or U.S. territory.
• 1+ years of clinical experience required.
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
• Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook.
• Excellent verbal and written communication skills.
• Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.

Benefits

The Highlights:

• 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-$30 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.