Utilization Review Nurse LVN/LPN

Job Summary:

• Provide professional assessment and review for the medical necessity of treatment requests and plans.
• Work schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekend coverage as required.
• Refer requests that fall outside of established guidelines to advance review or senior care consultants.

Essential Functions/Responsibilities/Duties:

• Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO).
• Review plan document for benefit determinations and attempt to redirect providers and patients to PPO providers.
• Utilize MCG guidelines, medical policies, Medscape, and NCCN.

Required Knowledge, Skills, and Abilities:

• Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
• Proficiency in software applications including Microsoft Word, Excel, PowerPoint and Outlook.
• Ability to speak clearly and convey complex or technical information.

Benefits:

• Competitive base salary and benefits effective day one.
• Comprehensive medical and dental through our own health solutions.
• Paid Time Off, mental health support, and retirement planning.