Utilization Management Nurse, LVN/LPN
New
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NeueHealthHealthcare utilization management
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
- Microsoft Office
Requirements
- Hold an active, unrestricted California LVN/LPN nursing license.
- Have 2-3 years of clinical nursing experience.
- Have at least 1 year of experience in utilization review, case management, or a related field.
- Managed care experience with medical necessity reviews is strongly preferred.
- Experience with EMR systems and prior authorization platforms.
- Be proficient in Microsoft Office Suite, including Word, Excel, and Outlook.
- Demonstrate analytical and critical thinking skills.
- Have proficiency in medical terminology and pharmacology.
- Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM) certification is preferred.
Responsibilities
- Evaluate and process prior authorization requests using clinical guidelines, including Medicare, Medicaid/Medi-Cal criteria, MCG, or health plan-specific guidelines.
- Assess medical necessity and the appropriateness of requested services.
- Verify patient eligibility, benefits, and coverage details.
- Coordinate authorization activity with healthcare providers, patients, and health plans.
- Communicate authorization decisions promptly and explain denials or alternative solutions.
- Collaborate with Medical Directors on adverse determinations and ensure notices meet regulatory requirements.
- Document authorization activities in electronic medical records or authorization systems.
- Maintain compliance with federal, state, and health plan regulations and stay updated on policy and clinical criteria changes.
- Identify trends in authorization denials and recommend process improvements.
- Participate in team meetings, training sessions, and audits.
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