Utilization Review Specialist - LPN

Desert Parkway Behavioral Healthcare Hospital•Las Vegas, NV

11d•Onsite

About The Position

We are looking for a detailed-oriented Utilization Review (UR) Specialist to help us maximize patient care quality and ensure seamless insurance operations. The UR Specialist evaluates patient medical records to ensure treatments meet clinical necessity and regulatory standards. You will serve as the primary bridge between our medical staff and insurance providers, facilitating timely care approvals and minimizing claim denials.

Requirements

Active State of Nevada Licensed Practical Nurse (LPN) license required
Minimum two (2) years of clinical experience, with 1+ years in utilization review or case management
Knowledge of Nevada Payors required
Strong Microsoft word and excel skills required
Maintains confidentiality of patients at all times

Responsibilities

Evaluate outpatient charts against established clinical criteria.
Submit and track insurance authorization requests.
Draft and submit clinical appeals for denied services.
Communicate directly with insurance medical directors and case managers.
Advise physicians and clinical staff on documentation requirements.
Monitor utilization trends, denial rates, and approval timelines.
Ensure adherence to Medicare, Medicaid, and private payer guidelines.
Retrieve discharge documents on a daily basis from charts, faxing when applicable, and retrieving authorizations.