LVN Utilization Review (In Office)
About The Position
The LVN Utilization Review role is pivotal in ensuring that patient care services are delivered efficiently and in accordance with established clinical guidelines and regulatory requirements. This position involves the thorough evaluation of medical records and treatment plans to determine the appropriateness, necessity, and efficiency of healthcare services provided to patients. The LVN Utilization Reviewer collaborates closely with healthcare providers, insurance companies, and case managers to facilitate optimal patient outcomes while managing healthcare costs. This role requires a keen eye for detail, strong clinical knowledge, and the ability to interpret complex medical information to support decision-making processes. Ultimately, the LVN Utilization Reviewer helps maintain high standards of care and compliance within healthcare organizations across the United States.
Requirements
- Current and valid Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license in the United States.
- Minimum of 2 years clinical nursing experience, preferably in acute care or related healthcare settings.
- Basic understanding of medical terminology, clinical procedures, and healthcare documentation.
- Familiarity with utilization review processes and healthcare regulations such as Medicare and Medicaid guidelines.
- Strong written and verbal communication skills.
Nice To Haves
- Experience in utilization review, case management, or healthcare quality assurance.
- Certification in Utilization Review or Case Management (e.g., Certified Professional in Utilization Review - CPUR).
- Proficiency with electronic medical records (EMR) systems and healthcare data management software.
- Knowledge of insurance payer policies and healthcare reimbursement methodologies.
- Minimum Associate degree in Nursing
- Prior home health experience and strong knowledge with wounds and wound care treatments
Responsibilities
- Review patient medical records and clinical documentation to assess the necessity and appropriateness of healthcare services.
- Evaluate treatment plans and healthcare interventions against established clinical guidelines and payer policies.
- Communicate effectively with physicians, nurses, case managers, and insurance representatives to clarify clinical information and resolve discrepancies.
- Prepare detailed reports and documentation to support utilization review decisions and ensure compliance with regulatory standards.
- Monitor ongoing patient care to identify opportunities for care coordination, discharge planning, and resource optimization.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
11-50 employees
