Prior Authorization LVN

LSMA Management Inc; San Bernardino (CA); On-site; USD 48,216 - 55,104; Full time

Job summary

LSMA Management Inc. is seeking a Prior Authorization Nurse (LVN) in California to perform clinical review of authorization requests, ensure medical necessity and regulatory compliance.

This role conducts prospective, concurrent, and retrospective reviews for services including specialty care, diagnostics, elective admissions, and post-acute services, collaborating with providers, health plans, and internal teams.

Qualifications

• California LVN license in good standing.
• High School diploma or equivalent; LVN program graduate.
• 1+ year clinical healthcare experience.
• Utilization management or managed care experience preferred.
• Ability to review clinical data and apply criteria accurately.

Responsibilities

• Perform prospective, concurrent, and retrospective review of medical services to determine medical necessity.
• Collaborate with providers, health plans, and clinical teams to coordinate care.
• Support utilization management operations and adherence to CMS/NCQA guidelines.
• Serve as clinical resource to Prior Authorization Coordinators.

Skills

Utilization management principles

Clinical communication

Regulatory knowledge (NCQA CMS HIPAA)

Documentation & accuracy

Organizational skills

Independent & team work

MS Office (Word Excel Outlook)

EMR/authorization systems

Adaptability to new software

Education

Graduate from LVN program

California LVN license

High School diploma or equivalent

Tools

MCG (Milliman Care Guidelines)

InterQual criteria

EMR systems

Authorization systems

Job description

Description

JOB SUMMARY:

The Prior Authorization Nurse (LVN) is responsible for performing clinical review and evaluation of authorization requests to ensure medical necessity, appropriate utilization of healthcare services, and compliance with regulatory and health plan requirements. This role conducts prospective, concurrent, and retrospective review of medical services including specialty care, diagnostic procedures, elective admissions, post-acute services, and out-of-network referrals. The Prior Authorization LVN collaborates with providers, health plans, and internal clinical teams to support timely care coordination while ensuring adherence to CMS, NCQA, and organizational guidelines. The position serves as a clinical resource to Prior Authorization Coordinators and supports efficient utilization management operations.

Requirements

MINIMUM & PREFERRED QUALIFICATIONS:

Education/Training

Minimum: High School diploma or equivalent required. Graduate from an accredited Vocational Nursing Program.

Experience

Minimum: At least one year of clinical experience in a healthcare setting. Basic knowledge of medical terminology, utilization management processes, and clinical care practices.

Preferred: Two or more years of utilization management, prior authorization, case management, or managed care experience. Experience working in an MSO, IPA, health plan, or medical group environment. Experience using Milliman Care Guidelines (MCG), InterQual, or similar criteria tools. Knowledge of ICD-10, CPT, and HCPCS coding. Experience with electronic health record and utilization management systems.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Current, active, unrestricted California LVN license required.

Skills, Knowledge & Abilities

• · Knowledge of utilization management principles, medical necessity criteria, and managed care processes.
• · Understanding of clinical documentation and healthcare delivery systems.
• · Familiarity with regulatory requirements including NCQA, CMS, and HIPAA.
• · Strong verbal and written communication skills.
• · Ability to effectively communicate with physicians, providers, and interdisciplinary teams.
• · Ability to provide clear and professional clinical guidance.
• · Ability to review and interpret clinical information and apply established criteria.
• · Strong organizational and prioritization skills.
• · Ability to manage multiple tasks and deadlines efficiently.
• · Proficiency in Microsoft Office (Word, Excel, Outlook).
• · Ability to use electronic medical records and authorization systems.
• · Ability to learn and adapt to new software and technology.
• · Strong attention to detail and accuracy.
• · Ability to maintain confidentiality and professionalism.
• · Ability to work independently and as part of a team.
• · Ability to review and interpret clinical information and apply established criteria.
• · Strong organizational and prioritization skills.
• · Ability to manage multiple tasks and deadlines efficiently.
• · Proficiency in Microsoft Office (Word, Excel, Outlook).
• · Ability to use electronic medical records and authorization systems.
• · Ability to learn and adapt to new software and technology.
• · Strong attention to detail and accuracy.
• · Ability to maintain confidentiality and professionalism.
• · Ability to work independently and as part of a team.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS:

The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job. Prolonged sitting, typing, and computer work. Occasional standing, walking, bending, and reaching. Ability to lift up to 20 pounds occasionally. Ability to concentrate for extended periods while reviewing clinical documentation. Ability to manage multiple priorities in a fast-paced environment. Ability to exercise sound clinical judgment and decision-making. Frequent interaction with healthcare providers and internal staff via phone and electronic communication. Low to moderate noise level consistent with office environment.

PAY RANGE

$35.00 - $40.00 / hourly