Utilization Management Nurse, LVN/LPN

Job Summary

The Concurrent Utilization Review (UR) Nurse is responsible for conducting real-time clinical reviews to ensure the medical necessity and appropriateness of healthcare services provided to members under a managed care health plan. This role involves assessing inpatient admission and continued stays, coordinating with healthcare providers, facilitating communication with payers, and ensuring compliance with health plan policies and clinical guidelines. The UR Nurse collaborates with the Medical Director and clinical leadership for complex cases, denials, and escalated reviews.

Key Responsibilities

• Concurrent Review & Case Assessment
  • Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness based on established clinical guidelines (e.g., InterQual, MCG).
  • Evaluate clinical documentation to support level-of-care determinations, treatment plans, and continued hospital stays.
  • Ensure adherence to health plan policies, clinical criteria, and regulatory requirements.
• Collaboration with Medical Director
  • Review and escalate complex or borderline cases to the Medical Director for further assessment.
  • Provide the Medical Director with comprehensive clinical summaries, including case history, treatment plans, and justifications for continued care or level-of-care decisions.
  • Collaborate with the Medical Director to develop treatment recommendations and resolve discrepancies in care.
• Authorization & Payer Communication
  • Process authorization requests for inpatient hospital admissions, LTAC, inpatient rehab, and skilled nursing admissions.
  • Communicate with healthcare providers to request additional documentation or clarify treatment plans.
  • Ensure timely approvals or denials of requested services per the health plan’s benefit structure and clinical guidelines.
  • Escalate cases to the Medical Director or higher clinical authority when necessary.
• Care Coordination & Discharge Planning Support
  • Work closely with case managers, social workers, and care teams to facilitate seamless care transitions.
  • Participate in interdisciplinary discussions to address complex cases and ensure members receive appropriate care.
  • Identify and escalate discharge barriers to support timely and effective discharge planning.
  • Assist in transitioning patients from inpatient to outpatient or post-acute care settings.
• Compliance & Documentation
  • Ensure compliance with state and federal regulations, accreditation standards (e.g., NCQA, URAC), and health plan policies.