LPN UM Reviewer

ebnhc; Boston (MA); On-site; USD 45,000 - 66,000; Full time

Job summary

NeighborHealth in Boston is seeking an experienced LPN UM Reviewer to support the Utilization Management team. You will review authorization requests, apply medical necessity criteria, coordinate care with providers, and ensure regulatory compliance.

The role requires an LPN license, familiarity with managed care, and strong documentation, communication, and computer skills. This full-time position is based at 10 Gove Street, Taylor Building, with competitive hourly pay based on experience.

Qualifications

• Current, unrestricted LPN license.
• Experience in managed care, utilization management, or clinical review preferred.
• Knowledge of medical terminology, healthcare regulations, and clinical documentation.
• Strong organizational, communication, and computer skills.

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.

Skills

LPN license

Organizational skills

Communication skills

Computer skills

Education

LPN license

Tools

EMR systems

Authorization management systems

Job description

Thank you for your interest in a career at NeighborHealth, formerly East Boston Neighborhood Health Center!

As one of the largest community health centers in the country, NeighborHealth is proud to serve the greater Boston area with a strong commitment to the health and well-being of our patients and communities.

Whether you're a nurse or physician providing direct care, a manager leading dedicated teams, or part of the essential support staff who keep our operations running smoothly - every role at NeighborHealth is vital. Together, we're advancing medicine and delivering the best care experience for our patients and community!

Time Type: Full time

Department: Senior Care Options (SCO)

All Locations: 10 Gove Street - Taylor Building

Position Summary

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.

Preferred Experience

• Experience with Medicare, Medicaid, SCO, One Care, or managed care programs.
• Familiarity with InterQual, MCG, or other medical necessity criteria tools.
• Experience using EMRs and authorization management systems.

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 [e-mail] or call 617-568-4480 to let us know the nature of your request

E-Verify Program Participation Statement

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.