Utilization Management Nurse, LVN/LPN (Work from Home)
About The Position
The Utilization Management (UM) Prior Authorization (PA) Nurse is a full-time role dedicated to promoting quality and cost-effective outcomes for a designated population. Working with Medical Directors and the clinical team, the nurse ensures members receive appropriate benefit coverage for services requiring prior authorization. The role reviews requests for treatments, medications, procedures, and diagnostic tests for compliance with contract requirements, coverage policies, and evidence-based medical necessity criteria. It also involves collecting and analyzing utilization data and monitoring quality and appropriate service use. The position requires clinical expertise, attention to detail, and strong communication with healthcare providers, patients, and health plans. For individuals assigned to a location in California, the stated reasonable compensation estimate is $27.10–$40.65 per hour. Actual compensation varies based on education, experience, skills, abilities, and internal equity. Employees are eligible for health benefits; life and disability benefits; a 401(k) savings plan with match; paid time off; and paid holidays.
Requirements
- Active, unrestricted California Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license.
- At least 2–3 years of clinical nursing experience, including at least 1 year in utilization review, case management, or a related field.
- Strong analytical and critical thinking skills.
- Proficiency in medical terminology and pharmacology.
- Effective written and verbal communication skills.
- Ability to work independently and collaboratively in a fast-paced environment.
- Adaptable and self-motivated.
- Experience with EMR systems and prior authorization platforms.
- Proficiency in Microsoft Office Suite, including Word, Excel, and Outlook.
Nice To Haves
- Experience in a managed care setting with medical necessity reviews.
- Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM) certification.
- Additional clinical nursing or case management certifications.
Responsibilities
- Evaluate and process prior authorization requests using applicable clinical guidelines, including Medicare, Medicaid/Medi-Cal criteria, MCG, or health plan-specific guidelines.
- Assess medical necessity and the appropriateness of requested services using clinical expertise.
- Verify patient eligibility, benefits, and coverage details.
- Act as a liaison among healthcare providers, patients, and health plans to facilitate authorization.
- Communicate authorization decisions promptly to providers and patients.
- Explain denials or alternative solutions and collaborate with Medical Directors on adverse determinations.
- Ensure adverse determination notices comply with regulatory requirements, including readability standards and appeal information.
- Document authorization activities accurately in electronic medical records or authorization systems.
- Maintain compliance with federal, state, and health plan regulations and stay updated on policy and clinical criteria changes.
- Identify trends or recurring issues in authorization denials and recommend process improvements.
- Participate in team meetings, training sessions, and audits to support high-quality performance.
Benefits
- Health benefits
- Life and disability benefits
- 401(k) savings plan with match
- Paid Time Off
- Paid holidays
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
