UM LVN: Clinical Reviewer & Care Coordination Expert

Advanced Medical Management, Inc.; Long Beach (CA); On-site; USD 72,000 - 105,000; Full time

Benefits offered by this job

Health coverage

Vision & dental premiums discount

FSAs and 401(k)

PTO & sick leave

Tuition reimbursement

Team outings

Job summary

Advanced Medical Management, Inc. is seeking an LVN to support Utilization Management activities in California.

The role involves clinical review for prior authorizations, concurrent and retrospective reviews, and care coordination within EZCAP and related systems. You will apply evidence-based criteria and health plan guidelines to ensure medical necessity, timeliness, and cost-effectiveness while maintaining compliance with CMS, DMHC, NCQA, and delegated health plan requirements.

Qualifications

• Graduate of an accredited Vocational Nursing Program.
• Current California Licensed Vocational Nurse (LVN) license in good standing.

Responsibilities

• Perform clinical reviews for prior authorization using approved criteria (MCG, InterQual, CMS, health plan guidelines).
• Review outpatient, inpatient, DME, imaging, therapy, home health, and specialty referrals.
• Determine medical necessity within LVN scope of practice.
• Identify cases needing Medical Director review.
• Monitor turnaround times to ensure regulatory compliance.
• Prioritize expedited and urgent authorization requests.
• Coordinate discharge planning with Case Management.
• Communicate with providers to obtain necessary documentation.
• Educate providers about UM requirements.

Skills

Clinical assessment

Critical thinking

Time management

Organizational skills

Professional communication

Prioritizing multiple requests

Team collaboration

Education

CA LVN license; accredited Vocational Nursing Program

Tools

EZCAP

EZNET

MCG/InterQual

Medi-Cal Managed Care

Prior Authorization

Concurrent Review

Case Management

Job description

Advanced Medical Management, Inc. is seeking an LVN to support Utilization Management activities in California.

The role involves clinical review for prior authorizations, concurrent and retrospective reviews, and care coordination within EZCAP and related systems. You will apply evidence-based criteria and health plan guidelines to ensure medical necessity, timeliness, and cost-effectiveness while maintaining compliance with CMS, DMHC, NCQA, and delegated health plan requirements.