LPN Utilization Reviewer – Care Authorization

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

Job summary

NeighborHealth is seeking an LPN UM Reviewer to support the Utilization Management team within the Senior Care Options (SCO) department. You will review authorization requests, apply medical necessity criteria, and coordinate care with providers and care managers in the Boston area.

Role requires current LPN licensure, knowledge of regulations, and proficiency with EMR and authorization systems. You will document decisions, monitor turnaround times, and assist with appeals and audits as part of

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.

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

Managed Care

Utilization Management

Prior Authorization

Clinical Review

Medical Terminology

Healthcare Regulations

Documentation

Organizational Skills

Communication Skills

Independent Work

Multitasking

Tools

EMR Software

Authorization Management Systems

Job description

NeighborHealth is seeking an LPN UM Reviewer to support the Utilization Management team within the Senior Care Options (SCO) department. You will review authorization requests, apply medical necessity criteria, and coordinate care with providers and care managers in the Boston area.

Role requires current LPN licensure, knowledge of regulations, and proficiency with EMR and authorization systems. You will document decisions, monitor turnaround times, and assist with appeals and audits as part of