Utilization Review Nurse-LVN/LPN

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Under the supervision of a registered nurse the Utilization Review Nurse will provide professional assessment and review for the medical necessity of treatment requests and plans. The standard work schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekend coverage as required.

Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity; and all post claim or post service reviews. Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO). Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care. Refer requests that fall outside of established guidelines to advance review or senior care consultants. Process appeals for non-certification of services; complete non-certification letters when appropriate. Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers. Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together program. Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality. Utilize MCG guidelines, medical policies, Medscape, and NCCN. Ability to meet productivity, quality, and turnaround times daily. Assists with department operations and implementations