UM Review Nurse

Jobtailor; Monterey Park (CA); On-site; USD 55,000 - 85,000; Full time

Job summary

Jobtailor in California is seeking an LVN to support outpatient Utilization Management, applying clinical judgment to determine medical necessity and coordinate approvals.

The role requires state licensure, at least 1 year in outpatient UM, proficiency with Microsoft Word, Excel, and Outlook, and ability to work with health plans, IPA, or MSO environments.

Qualifications

• Active and unrestricted LVN license in California.
• At least 1 year of outpatient Utilization Management experience.
• Experience with Microsoft Word, Excel, and Outlook.
• Candidates must live in California.
• At least 2 years of health plan, IPA, or MSO experience preferred as a strong fit.
• Strong interpersonal skills.
• Ability to collaborate with co-workers, senior leadership, and other management.
• Experience educating and training staff.

Responsibilities

• Utilize clinical judgment to approve or deny outpatient medical services based on Medical Necessity Criteria for various Health Plans
• Complete prior authorization and retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment
• Refer cases to Medical Directors as needed or appropriate
• Maintain knowledge of state and federal regulations and accreditation standards
• Comply with internal policies and procedures
• Perform other job duties as requested

Skills

Clinical Judgment

Interpersonal Skills

Collaboration

Staff Education and Training

Education

Licensed Vocational Nurse (LVN) - California

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

• Utilize clinical judgment to approve or deny outpatient medical services based on Medical Necessity Criteria for various Health Plans


• Complete prior authorization and retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment


• Refer cases to Medical Directors as needed or appropriate


• Maintain knowledge of state and federal regulations and accreditation standards


• Comply with internal policies and procedures


• Perform other job duties as requested

Requirements

• Active and unrestricted LVN license in California


• At least 1 year of outpatient Utilization Management experience


• Experience with Microsoft Word, Excel, and Outlook


• Candidates must live in California


• At least 2 years of health plan, IPA, or MSO experience preferred as a strong fit


• Strong interpersonal skills


• Ability to collaborate with co-workers, senior leadership, and other management


• Experience educating and training staff

Core Competencies

Demonstrates expertise in outpatient Utilization Management, applying clinical judgment to assess medical necessity and ensure compliance with state and federal regulations. Proficient in collaborating with healthcare teams and educating staff to enhance service delivery.

Highest-signal resume keywords

• Active LVN License in California


• Outpatient Utilization Management Experience


• Health Plan Experience


• Microsoft Office Proficiency


• Interpersonal Skills

Hard Skills

• Clinical Judgment


• Prior Authorization


• Retrospective Review


• Medical Necessity Criteria


• Elective Inpatient Admissions


• Outpatient Procedures


• Durable Medical Equipment Review


• State and Federal Regulations Knowledge


• Accreditation Standards Compliance

Soft Skills

• Strong Interpersonal Skills


• Collaboration


• Staff Education and Training

Certifications & Qualifications

• Active LVN License

Industry Keywords

• Utilization Management


• Health Plans


• IPA


• MSO


• Medical Directors

Tools & Technologies

• Microsoft Word


• Microsoft Excel


• Microsoft Outlook