Prior Authorization LVN
About The Position
The Prior Authorization Nurse (LVN) is responsible for performing clinical review and evaluation of authorization requests to ensure medical necessity, appropriate utilization of healthcare services, and compliance with regulatory and health plan requirements. This role conducts prospective, concurrent, and retrospective review of medical services including specialty care, diagnostic procedures, elective admissions, post-acute services, and out-of-network referrals. The Prior Authorization LVN collaborates with providers, health plans, and internal clinical teams to support timely care coordination while ensuring adherence to CMS, NCQA, and organizational guidelines. The position serves as a clinical resource to Prior Authorization Coordinators and supports efficient utilization management operations.
Requirements
- High School diploma or equivalent required.
- Graduate from an accredited Vocational Nursing Program.
- At least one year of clinical experience in a healthcare setting.
- Basic knowledge of medical terminology, utilization management processes, and clinical care practices.
- Current, active, unrestricted California LVN license required.
- Knowledge of utilization management principles, medical necessity criteria, and managed care processes.
- Understanding of clinical documentation and healthcare delivery systems.
- Familiarity with regulatory requirements including NCQA, CMS, and HIPAA.
- Strong verbal and written communication skills.
- Ability to effectively communicate with physicians, providers, and interdisciplinary teams.
- Ability to provide clear and 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, Outlook).
- Ability to use electronic medical records and authorization systems.
- Ability to learn 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.
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.
Responsibilities
- Perform clinical review and evaluation of authorization requests.
- Ensure medical necessity, appropriate utilization of healthcare services, and compliance with regulatory and health plan requirements.
- Conduct prospective, concurrent, and retrospective review of medical services including 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.
- Ensure adherence to CMS, NCQA, and organizational guidelines.
- Serve as a clinical resource to Prior Authorization Coordinators.
- Support efficient utilization management operations.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
