Utilization Management Nurse, LVN/LPN
N
NeueHealthHealthcare
Location: California, United StatesFull-TimeJunior
Salary27.1 - 40.65 USD per hour
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Job Details
- Experience
- Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a related field.
- Required Skills
- Communication SkillsAnalytical SkillsMicrosoft ExcelMicrosoft Office SuiteCritical thinking
Requirements
- Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required.
- Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a related field.
- Experience in a managed care setting with medical necessity reviews is strongly preferred.
- Strong analytical and critical thinking skills.
- Proficiency in medical terminology and pharmacology.
- Effective written and verbal communication skills.
- Ability to work independently and collaboratively in a fast-paced environment.
- Adaptable and self-motivated.
- Experience with EMR systems and prior authorization platforms.
- Proficient in Microsoft Office Suite (Word, Excel, Outlook).
Responsibilities
- Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, Medicaid/Medi-Cal criteria, MCG, or health plan-specific guidelines.
- Assess medical necessity and the appropriateness of requested services using clinical expertise.
- Verify patient eligibility, benefits, and coverage details.
- Act as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process.
- Communicate authorization decisions to providers and patients promptly.
- Provide detailed explanations for denials or alternative solutions and collaborate with Medical Directors on adverse determinations.
- Accurately document all authorization activities in electronic medical records (EMR) or authorization systems.
- Maintain compliance with federal, state, and health plan regulations.
- Stay updated on policy and clinical criteria changes.
- Identify trends or recurring issues in authorization denials and recommend process improvements.
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