Prior Authorization LVN
About The Position
The Prior Authorization Nurse (LVN) performs clinical review and evaluation of authorization requests to assess medical necessity, appropriate utilization of healthcare services, and compliance with regulatory and health plan requirements. The role conducts prospective, concurrent, and retrospective reviews of medical services, including specialty care, diagnostic procedures, elective admissions, post-acute services, and out-of-network referrals. The LVN collaborates with providers, health plans, and internal clinical teams to support timely care coordination and adherence to CMS, NCQA, and organizational guidelines. The position also serves as a clinical resource to Prior Authorization Coordinators and supports efficient utilization management operations.
Requirements
- High school diploma or equivalent.
- Graduation from an accredited Vocational Nursing Program.
- At least one year of clinical experience in a healthcare setting.
- Current, active, unrestricted California LVN license.
- Basic knowledge of medical terminology, utilization management processes, and clinical care practices.
- Knowledge of utilization management principles, medical necessity criteria, managed care processes, clinical documentation, and healthcare delivery systems.
- Familiarity with NCQA, CMS, and HIPAA requirements.
- Strong verbal and written communication skills, including the ability to communicate effectively with physicians, providers, and interdisciplinary teams and provide clear, professional clinical guidance.
- Ability to review and interpret clinical information and apply established criteria.
- Strong organizational and prioritization skills; ability to manage multiple tasks and deadlines efficiently.
- Proficiency in Microsoft Office (Word, Excel, and Outlook).
- Ability to use electronic medical records and authorization systems and adapt to new software and technology.
- Strong attention to detail and accuracy; ability to maintain confidentiality and professionalism.
- Ability to work independently and as part of a team.
- Ability to concentrate for extended periods while reviewing clinical documentation and exercise sound clinical judgment and decision-making.
Nice To Haves
- Two or more years of utilization management, prior authorization, case management, or managed care experience.
- Experience working in an MSO, IPA, health plan, or medical group environment.
- Experience using Milliman Care Guidelines (MCG), InterQual, or similar criteria tools.
- Knowledge of ICD-10, CPT, and HCPCS coding.
- Experience with electronic health record and utilization management systems.
- Any combination of education and work experience equivalent to the stated minimum requirements will be considered.
Responsibilities
- Conduct prospective, concurrent, and retrospective clinical reviews of authorization requests.
- Evaluate requests for medical necessity, appropriate utilization, and compliance with regulatory and health plan requirements.
- Review requests involving specialty care, diagnostic procedures, elective admissions, post-acute services, and out-of-network referrals.
- Collaborate with providers, health plans, and internal clinical teams to support timely care coordination.
- Provide clinical guidance and serve as a resource to Prior Authorization Coordinators.
- Support efficient utilization management operations.
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
