LVN - Quality Assurance/Utilization Review - Business Development - Full Time 8hr

As a Utilization Review Nurse, you assess medical records to determine medical necessity by applying policies and clinical guidelines during urgent and standard reviews. You document decisions using protocol sets and support review of medical claims and utilization practices. You complete medical necessity and level-of-care reviews and refer cases to Medical Directors when appropriate. You join a team focused on delivering high-quality patient care and supporting care decisions across the health system.

• Evaluate medical records to determine medical necessity for services
• Document decisions using clinical guidelines and protocol sets
• Support and review medical claims and utilization practices
• Complete medical necessity and level-of-care reviews for requested services
• Refer cases to Medical Directors for review based on findings

• Three years of utilization management experience
• Current California LVN license
• Computer proficiency
• Excellent customer service skills
• Experience in quality-related roles (preferred)

• Customer service
• Communication
• Teamwork
• Utilization management
• Clinical judgment
• Documentation/compliance