LVN Utilization Review Nurse

To support timely and accurate benefit determinations, the full-time LVN Utilization Review Nurse will conduct first-level clinical reviews of treatment requests, ensuring compliance with clinical guidelines while working Monday to Friday with occasional Saturday coverage. Key responsibilities Provide first-level review for outpatient pre-certification requests and inpatient hospital stays to assess medical necessity Process appeals for non-certification of services and complete necessary documentation in compliance with established guidelines Collaborate with hospital staff to facilitate patient discharge and transition to the next level of care Required qualifications Current LVN license in the United States or U.S. territory At least 1 year of clinical experience Knowledge of medical claims and ICD-10, CPT, HCPCS coding Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook Familiarity with MCG guidelines and medical policies