LPN UM Reviewer

LPN UM Reviewer

The LPN UM Reviewer supports the Utilization Management team by reviewing authorization requests, monitoring medical necessity criteria, coordinating care with providers, and ensuring compliance with health plan and regulatory requirements.

Key Responsibilities

• Review prior authorization requests for medical services, medications, DME, home health, and other healthcare services.
• Apply established clinical guidelines and medical necessity criteria when evaluating requests.
• Gather and review clinical documentation from providers and facilities.
• Communicate with providers, care managers, and interdisciplinary team members regarding authorization decisions and required documentation.
• Escalate complex cases or requests that require RN or Medical Director review.
• Document determinations and activities accurately in utilization management systems.
• Monitor authorization turnaround times and regulatory compliance requirements.
• Support appeals, reconsiderations, and grievance processes as assigned.
• Participate in quality improvement and audit activities.

Qualifications

• Current, unrestricted LPN license.
• Experience in managed care, utilization management, case management, prior authorization, or clinical review preferred.
• Knowledge of medical terminology, healthcare regulations, and clinical documentation.
• Strong organizational, communication, and computer skills.
• Ability to work independently and manage multiple priorities.

Salary: Starting at $33/hr up to $48/hr based on experience

EEO & Accommodation Statement:

NeighborHealth is an equal employment/affirmative action employer. We ensure equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic. If you need accommodation for any part of the application process because of a medical condition or disability, please send an e-mail to View email address on click.appcast.io or call View phone number on click.appcast.io to let us know the nature of your request

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NeighborHealth participates in the Electronic Employment Verification Program, E-Verify. As an E-Verify employer, all prospective employees must complete a background check before beginning employment.