LVN - Utilization Management

HARBOR HEALTH; Austin (TX); Remote; USD 60,000 - 80,000; Full time

Benefits offered by this job

Competitive salary

Comprehensive benefits

Job summary

Harbor Health is seeking a dedicated Utilization Management (UM) LVN to support prior authorization and utilization review activities, ensuring timely access to care. This fully remote role collaborates with providers, members, and the UM team to facilitate determinations and regulatory compliance.

The position requires an LVN license and 2–3 years of clinical experience, with familiarity in CPT codes, NCQA processes, and UM platforms.

Qualifications

• Current, unrestricted LVN license.
• Minimum of 2–3 years of clinical experience; prior UM/Case Management preferred.
• Knowledge of TX social service programs; NCQA familiarity helpful.
• Knowledge of CPT codes and prior authorization requirements.
• Experience with utilization review processes and medical necessity determinations.
• Strong organizational and communication skills; ability to work independently and in a team.

Responsibilities

• Coordinate and manage prior authorization workflows with the UM team.
• Monitor authorization requests via fax/phone and enter cases into tracking system.
• Review clinical docs and CPT codes to determine prior authorization needs.
• Submit cases to UR vendor for medical necessity determinations.
• Maintain case documentation and track status to meet regulatory timelines.
• Draft and send notification letters to providers and members.
• Coordinate concurrent documentation from hospitals and post-acute facilities.
• Communicate missing information to expedite review and authorization.
• Support high-need/high-cost members with ongoing communication and care coordination.
• Assist with transitions of care and post-discharge coordination as applicable.

Skills

Organizational skills

Workflow management

Communication skills

Google Workspace

EHR systems

Electronic UM platforms

Multitasking

Education

Licensed Vocational Nurse (LVN) license

Tools

EHR systems

UM platforms

Google Workspace

Job description

Harbor Health is seeking a dedicated Utilization Management (UM) LVN. The UM LVN supports prior authorization and utilization review activities to ensure timely and appropriate access to care. This role collaborates with the UM team, providers, and members to facilitate authorization processes, coordinate clinical information, support medical necessity determinations, and maintain regulatory compliance. The UM LVN also provides ongoing communication and coordination support for high-need and high-cost members to promote appropriate utilization and continuity of care.

Shifts and Business Hours

This position is fully remote Monday-Friday 8am - 5pm with the exception of Saturday coverage once every 5 weeks on rotation for 4 hours.

POSITION DUTIES & RESPONSIBILITIES

Coordinate and manage prior authorization workflows in collaboration with the Utilization Management (UM) team.

Monitor incoming authorization requests via fax and phone and ensure timely case entry into the designated tracking system and UM platform.

Review submitted clinical documentation and verify CPT codes to determine prior authorization requirements.

Prepare and submit applicable cases to the contracted utilization review (UR) vendor for medical necessity determinations.

Maintain accurate case documentation and track status to ensure compliance with regulatory turnaround times.

Draft provider, facility, and member notification letters based on determination outcomes.

Coordinate mailing and faxing of approved determination letters to appropriate parties and ensure proper documentation.

Obtain and coordinate concurrent clinical documentation from hospitals, post-acute facilities, and other treating providers.

Communicate with providers and facilities regarding required or missing clinical information to facilitate timely review.

Provide clear communication to members and requesting providers regarding authorization status and documentation needs.

Support high-need and high-cost members through ongoing communication and coordination to promote appropriate utilization and continuity of care.

Assist with transitions of care and post-discharge coordination as applicable.

Perform all duties in compliance with organizational policies and applicable state and federal regulatory requirements.

Provide direct support to members with chronic diseases, ensuring continuity of care across chronic care pathways.

Communicate regularly with members to assess progress, resolve barriers to care, and promote adherence to treatment plans.

DESIRED PROFESSIONAL SKILLS & EXPERIENCE

Current, unrestricted LVN license.

Minimum of 2–3 years of clinical experience; prior Utilization Management or Case Management experience preferred.

Knowledge of Texas social service programs for members in need, both local and state-wide, preferred.

Familiarity with NCQA processes and requirements.

Knowledge of CPT codes and prior authorization requirements.

Familiarity with utilization review processes and medical necessity determinations.

Strong organizational and workflow management skills.

Excellent written and verbal communication skills.

Ability to assess member needs, provide education, and elevate concerns appropriately.

Proficiency in Google Workspace, EHR systems and electronic UM platforms.

Ability to manage multiple cases while meeting regulatory timelines.

Ability to work independently and within a team-based model to deliver excellent care.

WHAT WE OFFER

The opportunity to make a meaningful impact on utilization management and member outcomes

A collaborative and innovative work environment committed to member-centered care

An organization passionate about improving healthcare delivery in Austin and beyond

Competitive salary and comprehensive benefits package

Professional development and opportunities for career growth

A transparent, supportive, and inclusive culture that values every team member’s contributions

COMPANY OVERVIEW

At Harbor Health, we're transforming healthcare in Texas through collaboration and innovation. We're seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model. If you're ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!

EQUAL EMPLOYMENT OPPORTUNITY

Harbor Health is an Equal Opportunity Employer. We celebrate diversity and are committed to building an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic.