Job Summary:
This position is accountable for providing proficient direct and indirect nursing care of patients/families assigned under the direction and supervision of a physician and/or Registered Nurse. LVN practice is performed within the scope of LVN licensure and in accordance with Valley Children's policies.
Qualifications:
Position Summary
The Utilization Management (UM) Licensed Vocational Nurse (LVN) supports the UM department with clinical documentation review, authorization processing, information gathering, and care coordination. Under the direction of an RN or UM leadership, the LVN assists with timely authorization of services, appropriate resource utilization, and compliance with payer and regulatory requirements.
Essential Duties and Responsibilities
Clinical Review and Authorization
Review medical records and gather clinical documentation to support utilization review and authorization activities.
Identify missing information and coordinate with providers and care teams to obtain required documentation.
Submit and track concurrent authorization requests, follow up on pending determinations, and document approvals, denials, and extensions.
Assist RN Utilization Review staff with clinical screening and data collection.
Communicate authorization outcomes and required actions to appropriate team members.
Care Coordination and Communication
Collaborate with case managers, providers, social workers, and ancillary departments regarding authorization requirements and transitions of care.
Respond to inquiries from providers, payers, staff, patients, and families in a timely and professional manner.
Documentation and Compliance
Maintain accurate and timely documentation in the EMR and departmental systems.
Follow payer requirements, organizational policies, regulatory standards, and confidentiality guidelines.
Participate in audits, quality improvement initiatives, and utilization management data collection and reporting.
Knowledge, Skills, and Abilities
Knowledge of medical terminology, disease processes, hospital operations, and continuum of care.
Understanding of utilization management, prior authorization, and payer requirements.
Ability to review clinical documentation and identify required information.
Strong organizational, communication, and problem-solving skills with attention to detail.
Ability to manage competing priorities and meet deadlines.
Proficiency with electronic medical records and Microsoft Office.
Minimum Qualifications
Education
High School diploma/G.E.D. required
Graduate of an accredited LVN program or equivalent required
Licensure
Current California Licensed Vocational Nurse (LVN) license in good standing
BLS - Basic Life Support - AHA - American Heart Association within 30 days of hire or transfer into position (required)
Experience:
Minimum of two years of clinical nursing experience.
Pediatric healthcare experience preferred.
Experience in utilization management, case management, prior authorization, managed care, or insurance processes preferred.
Preferred Qualifications
Experience in an acute care pediatric hospital.
Familiarity with InterQual®, Milliman Care Guidelines (MCG), or other utilization review criteria.
Experience with managed Medicaid, commercial insurance plans, and CCS.
Reporting Relationship
Reports to: Supervisor, Utilization Management – Case Management.
Position Details
This is an on-site position working 4 x 8-hours shifts per week
Scope of Practice
The UM LVN functions within the scope of California LVN licensure and organizational policies. Responsibilities are limited to clinical information gathering, documentation review, authorization processing, and communication support.
Medical necessity determinations, independent clinical judgment, complex utilization reviews, denial management, and appeals remain the responsibility of the designated RN.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The…