Utilization Review Nurse (LVN) — Medical Necessity Expert

Gonzaba Medical Group; Cassin (TX); On-site; USD 45,000 - 65,000; Full time

Job summary

Gonzaba Medical Group seeks an LVN to join its Utilization Management team in San Antonio, TX. The role focuses on reviewing services for medical necessity, processing authorizations, and communicating determinations to the claims department and health plans.

A strong foundation in ICD-10/CPT-4 coding and HIPAA is required, with 2+ years in managed care preferred. The LVN will work to ensure timely reviews, participate in UM policy updates, and support other GMG departments as needed in a

Qualifications

• LVN certificate required or equivalent licensure.
• 2+ years in Managed Care/Utilization Management preferred.
• Strong knowledge of ICD-10 and CPT-4 coding.
• Excellent verbal and written communication skills.
• Able to work under pressure and meet deadlines.

Responsibilities

• Review and process claims to determine authorization for payment.
• Conduct medical necessity reviews using established criteria.
• Document decisions in EMR and MSO systems.
• Communicate findings to claims department and health plans.
• Participate in UM team meetings and process improvement efforts.

Skills

Nursing

ICD-10 CPT-4

Utilization Management

HIPAA

Communication

Education

LVN Certificate

Tools

MS Office

Job description

Gonzaba Medical Group seeks an LVN to join its Utilization Management team in San Antonio, TX. The role focuses on reviewing services for medical necessity, processing authorizations, and communicating determinations to the claims department and health plans.

A strong foundation in ICD-10/CPT-4 coding and HIPAA is required, with 2+ years in managed care preferred. The LVN will work to ensure timely reviews, participate in UM policy updates, and support other GMG departments as needed in a