Utilization Management LVN (Remote, Texas-based)

At Harbor Health, we’re transforming healthcare in Texas through collaboration and innovation. We’re seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model. If you’re ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!

Candidate should reside in Texas Harbor Health is seeking a dedicated Utilization Management (UM) LVN. The UM LVN supports prior authorization and utilization review activities to ensure timely and appropriate access to care. This role collaborates with the UM team, providers, and members to facilitate authorization processes, coordinate clinical information, support medical necessity determinations, and maintain regulatory compliance. The UM LVN also provides ongoing communication and coordination support for high-need and high-cost members to promote appropriate utilization and continuity of care. Shifts and Business Hours This position is fully remote Monday-Friday 8am - 5pm with the exception of Saturday coverage once every 5 weeks on rotation for 4 hours.

Coordinate and manage prior authorization workflows in collaboration with the Utilization Management (UM) team. Monitor incoming authorization requests via fax and phone and ensure timely case entry into the designated tracking system and UM platform. Review submitted clinical documentation and verify CPT codes to determine prior authorization requirements. Prepare and submit applicable cases to the contracted utilization review (UR) vendor for medical necessity determinations. Maintain accurate case documentation and track status to ensure compliance with regulatory turnaround times. Draft provider, facility, and member notification letters based on determination outcomes. Coordinate mailing and faxing of approved determination letters to appropriate parties and ensure proper documentation. Obtain and coordinate concurrent clinical documentation from hospitals, post-acute facilities, and other treating providers. Communicate with providers and facilities regarding required or missing clinical information to facilitate timely review. Provide clear communication to members and requesting providers regarding authorization status and documentation needs. Support high-need and high-cost members through ongoing communication and coordination to promote appropriate utilization and continuity of care. Assist with transitions of care and post-discharge coordination as applicable. Perform all duties in compliance with organizational policies and applicable state and federal regulatory requirements. Provide direct support to members with chronic diseases, ensuring continuity of care across chronic care pathways. Communicate regularly with members to assess progress, resolve barriers to care, and promote adherence to treatment plans.