Part-Time, UM LVN

Advanced Medical Management•Long Beach, CA

8d•$30 - $35

About The Position

The Utilization Management (UM) LVN is responsible for performing clinical review activities to support the prior authorization, concurrent review, retrospective review, and care coordination processes. Working within EZCAP and other clinical systems, the UM LVN applies evidence-based criteria and health plan guidelines to ensure medically necessary, appropriate, timely, and cost-effective healthcare services while maintaining compliance with CMS, DMHC, NCQA, and delegated health plan requirements. The UM LVN collaborates with physicians, providers, hospitals, case managers, and interdisciplinary staff to facilitate quality patient care and efficient utilization of healthcare resources.

Requirements

Graduate of an accredited Vocational Nursing Program.
Current California Licensed Vocational Nurse (LVN) license in good standing.
Minimum 2 years clinical nursing experience.
Knowledge of medical terminology.
Knowledge of disease processes.
Knowledge of Medicare regulations.
Knowledge of Managed Care principles.
Knowledge of Prior Authorization process.
Knowledge of Concurrent Review.
Knowledge of Clinical documentation.
Knowledge of Utilization Management.
Knowledge of Health Plan guidelines.
Knowledge of CMS requirements.
Knowledge of HIPAA regulations.
Knowledge of NCQA standards.
Strong clinical assessment skills.
Excellent documentation skills.
Critical thinking.
Time management.
Organizational skills.
Professional communication.
Customer service.
Ability to prioritize multiple requests.
Attention to detail.
Team collaboration.
Flexibility to work rotating schedules, including weekends and holidays, based on operational needs.

Nice To Haves

Minimum 1 year Utilization Management experience.
Experience in managed care.
Experience with Medicare Advantage.
Experience with EZCAP.
Experience with EZNET.
Experience with MCG or InterQual Criteria.
Experience with Medicare Advantage.
Experience with Medi-Cal Managed Care.
Experience with Delegated Medical Groups.
Experience with Prior Authorization.
Experience with Concurrent Review.
Experience with Case Management.

Responsibilities

Perform clinical review of prior authorization requests using approved clinical criteria (MCG, InterQual, CMS, Health Plan guidelines, etc.).
Review outpatient, inpatient, DME, imaging, therapy, home health, and specialty referrals.
Determine whether requests meet medical necessity criteria within LVN scope of practice.
Identify cases requiring Medical Director review.
Escalate complex or questionable cases appropriately.
Monitor turnaround times to ensure compliance with regulatory requirements.
Prioritize expedited and urgent authorization requests.
Perform continued stay reviews.
Monitor inpatient admissions and length of stay.
Coordinate discharge planning with Case Management.
Collaborate with hospitals regarding continued medical necessity.
Document complete and accurate clinical reviews in EZCAP.
Record medical necessity rationale.
Document provider communications.
Maintain detailed authorization notes.
Ensure documentation supports regulatory and audit requirements.
Contact provider offices to obtain additional clinical documentation.
Discuss authorization requirements.
Communicate approved services when appropriate.
Coordinate peer-to-peer review requests.
Educate providers regarding UM requirements.
Work closely with Medical Directors, UM Coordinators, Case Managers, Provider Relations, Claims, Health Plans, Hospitals, Skilled Nursing Facilities, and Home Health Agencies.
Maintain compliance with CMS Medicare Managed Care Manual, DMHC Knox-Keene requirements, NCQA UM Standards, Health Plan Delegation Agreements, Organizational UM Policies, and HIPAA Privacy Regulations.
Participate in internal audits.
Assist with corrective action plans.
Identify workflow improvements.
Participate in UM Committee initiatives.
Support delegation audit preparation.
Review authorization queues.
Update authorization status.
Route cases requiring physician review.
Document medical necessity findings.
Generate authorization notes.
Review member eligibility.
Maintain accurate case records.
Monitor work queues.
Ensure timely processing of referrals.