Senior Utilization Management Nurse, LVN/LPN
New
N
NeueHealthHealthcare
RemoteFull-TimeSenior
Salary not disclosed
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Job Details
- Experience
- Minimum of 4 years or more of clinical nursing experience, with at least 1 year in utilization review, case management, or a related field.
- Required Skills
- Microsoft OfficeEHR
Requirements
- Active, unrestricted California nursing license (RN or LVN/LPN).
- Minimum of 4 years of clinical nursing experience.
- Minimum of 1 year in utilization review, case management, or a related field.
- Strong knowledge of clinical guidelines such as InterQual and MCG.
- Experience in a managed care setting with medical necessity reviews.
- Proficiency in electronic health records (EHR) and utilization management software.
- Proficiency in Microsoft Office Suite.
- Excellent communication and interpersonal skills.
- Strong analytical skills and attention to detail.
- BSN preferred.
- Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM) preferred.
Responsibilities
- Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness.
- Evaluate clinical documentation to support level-of-care determinations and continued hospital stays.
- Process authorization requests for inpatient hospital admissions, LTAC, inpatient rehab, and skilled nursing.
- Collaborate with the Medical Director on complex cases, denials, and escalated reviews.
- Work with case managers and care teams to facilitate seamless care transitions and discharge planning.
- Ensure compliance with state/federal regulations, NCQA, and URAC standards.
- Educate providers and staff on clinical guidelines and authorization processes.
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