Utilization Review Nurse-LVN/LPN (Healthcare)

TL;DR

Utilization Review Nurse-LVN/LPN (Healthcare): Providing professional assessment and review for the medical necessity of treatment requests and plans with an accent on pre-certification requests and discharge planning. Focus on ensuring medical appropriateness, processing appeals, and maintaining accurate documentation using MCG guidelines.

Location: Remote, United States. Work schedule: Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekend coverage.

Compensation: $25–$29 per hour

Company

A personalized health platform bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together for employers and health systems.

What you will do

• Perform first-level review for outpatient and ancillary pre-certification requests and inpatient hospital stays for medical necessity.
• Ensure proper referral to medical directors for denial authorizations through independent review organizations.
• Collaborate with hospital staff to facilitate smooth patient discharge and transitions to the next level of care.
• Process appeals for non-certification of services and draft non-certification letters when appropriate.
• Utilize MCG guidelines, medical policies, Medscape, and NCCN to guide clinical reviews.
• Maintain detailed documentation for all reviews within Eldorado/Episodes systems while ensuring confidentiality.

Requirements

• Current LVN license in the United States or U.S. territory.
• 1+ years of clinical experience.
• Knowledge of medical claims and ICD-10, CPT, and HCPCS coding.
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, and Outlook).
• Excellent verbal and written communication skills to convey complex technical information.

Culture & Benefits

• Comprehensive medical and dental insurance effective from day one.
• Paid Time Off (PTO) to ensure rest and recharge.
• Mental health support, retirement planning, and financial protection.
• Professional development opportunities with clear career progression and learning budgets.
• Inclusive, mission-driven culture that values diversity and different perspectives.