LVN - Utilization Management (Remote)

This position is TEMPORARY until 12/20/2025 Monday to Friday 8am to 5pm The Utilization Management LVN is responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision making, as it relates to the application of criteria and application of defined levels of hierarchy and composition of compliant denial notices to review medical records, authorize requested services and prepare cases for physician review based on medical necessity. The position partners with both the Pre-Service and In-Patient Utilization Management teams. Ensures to monitor and assure the appropriateness and medical necessity of care as it relates to quality, continuity, and cost effectiveness.

Reviews designated requests for referral authorizations either proactively, concurrently, or retroactively. Gathering all information needed to make a determination and/or coordinate with the Medical Director as needed. Responsible to coordinate with contracting to obtain appropriate contracts as deemed appropriate. Identify cases that require additional case management. Composes denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards. Constructs denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member’s condition and request. Provides relevant clinical information to the request and the criteria used for decision-making. Ensures that there is evidence that the UM nurse reviewer documented communications with the requesting provider to validate the presence or absence of clinical information related to the criteria applied. Evaluates out-of-network and tertiary denials for accessibility within the network. Consults with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination. Escalates non-compliant cases to UM compliance and consistently reports on denial activities. Collaborates with the Delegation Oversight Department and compliance for continued quality improvement efforts for adverse determinations. Identifies gaps in training or process impacting the overall compliance of adverse determinations and communicates in writing an effective performance improvement solution.