Utilization Review Nurse I – LVN/LPN

Job Description:

• Evaluate requests for medical necessity, appropriate level of care, documentation completeness, and benefit coverage
• Review outpatient and ancillary pre-certification and prior authorization requests
• Review inpatient stays, including behavioral health, substance use, skilled nursing, and rehabilitation
• Perform post-service or post-claim reviews as assigned
• Apply internal medical policies, group-specific policies, NCCN, and MCG guidelines
• Record criteria and policy rationale in the utilization management system
• Refer cases outside guidelines, failing criteria, or potentially requiring adverse determination to senior staff or the Medical Director
• Support IRO referrals according to policy and jurisdictional requirements
• Review plan documents to support benefit determinations
• Redirect providers and members to PPO or in-network options when appropriate
• Prepare complete case summaries for Medical Director review, including adverse determination and IRO referral pathways
• Meet productivity, quality, and turnaround targets
• Participate in quality activities such as inter-rater reliability (IRRA)
• Apply feedback to maintain audit readiness for URAC, NCQA, and other applicable standards
• Protect member privacy and follow HIPAA and minimum-necessary standards
• Support team operations and service-level commitments
• Contribute to staff training as appropriate

Requirements:

• Graduate of an accredited nursing program (LVN/LPN)
• Current, unrestricted U.S. or U.S. territory nursing license; compact license acceptable where applicable
• Minimum 1-2 years of recent clinical experience in acute care, med-surg, ICU/ED, or another relevant setting
• Prior utilization review or utilization management experience preferred
• Ability to interpret medical records and apply evidence-based criteria and plan medical policies
• Working knowledge of MCG and NCCN clinical guidelines and UM documentation systems
• Proficiency with Microsoft Word, Excel, Outlook, and Teams
• Ability to learn additional tools as assigned
• Comfort working across multiple screens and a headset-based phone system
• Proficient typing and accurate data entry
• Ability to use remote-work technology such as VPN and departmental platforms such as SharePoint/Drives in line with security policies
• HIPAA and minimum-necessary standards compliance
• Required annual training and testing completed on time

Benefits:

• Competitive base salary
• Benefits effective day one
• Comprehensive medical and dental coverage
• Paid Time Off
• Mental health support
• Retirement planning
• Financial protection
• Professional development
• Clear career progression
• Learning budgets
• Wellness programs
• Other employee perks
• Mission-driven culture where diverse perspectives drive real impact