Prior Authorization LVN

LaSalle Medical Associates IPA; San Bernardino (CA); On-site; USD 48,000 - 55,000; Full time

Job summary

LaSalle Medical Associates IPA is seeking a Prior Authorization Nurse (LVN) to perform clinical review and evaluation of authorization requests, ensuring medical necessity and proper utilization of services. The role involves coordination with providers, health plans, and internal teams to maintain CMS, NCQA, and organizational compliance.

The position requires a California LVN license (current and active) and at least one year of clinical experience, with preferred exposure to utilization

Qualifications

• High School diploma or equivalent; graduate from an accredited Vocational Nursing Program.
• Minimum: at least one year of clinical experience in a healthcare setting.
• Preferred: two or more years in utilization management, prior authorization, case management, or managed care.

Responsibilities

• Perform prospective, concurrent, and retrospective review of medical services to ensure medical necessity.
• Collaborate with providers, health plans, and internal clinical teams to support care coordination.
• Ensure compliance with CMS, NCQA, HIPAA and organizational guidelines.
• Serve as clinical resource to Prior Authorization Coordinators and utilize management systems.

Skills

Utilization management

Clinical documentation

Regulatory compliance

Communication skills

Multitasking

Team collaboration

Education

High School diploma, Vocational Nursing Program graduate

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