Utilization Review LPN, FT

About the Role:

The Utilization Review Licensed Practical Nurse (LPN) plays a critical role in ensuring that patients receive appropriate and efficient healthcare services. This position involves evaluating the necessity, appropriateness, and efficiency of healthcare services provided to patients, with the goal of optimizing patient outcomes while managing healthcare costs. The Utilization Review LPN collaborates closely with healthcare providers, insurance companies, and case managers to review medical records, assess treatment plans, and determine coverage eligibility. This role requires a thorough understanding of clinical guidelines, healthcare regulations, and insurance policies to make informed decisions regarding patient care. Ultimately, the Utilization Review LPN helps maintain high standards of care and supports the healthcare system's sustainability by promoting effective resource utilization.

Minimum Qualifications:

• Current and valid Licensed Practical Nurse (LPN) license in the United States.
• Minimum of 2 years clinical nursing experience, preferably in acute care or related healthcare settings.
• Basic understanding of medical terminology, clinical procedures, and healthcare documentation.
• Familiarity with healthcare insurance processes and utilization review principles.
• Strong communication and organizational skills.

Preferred Qualifications:

• Experience in utilization review, case management, or healthcare quality assurance.
• Certification in Utilization Review or Case Management (e.g., Certified Professional in Utilization Review).
• Knowledge of healthcare regulations such as HIPAA and the Affordable Care Act.
• Proficiency with electronic medical records (EMR) systems and utilization review software.
• Additional nursing certifications or advanced training related to managed care or healthcare compliance.

Responsibilities:

• Review patient medical records and treatment plans to assess the necessity and appropriateness of care.
• Collaborate with physicians, nurses, case managers, and insurance representatives to gather and verify clinical information.
• Evaluate healthcare services against established clinical guidelines and insurance policies to determine coverage eligibility.
• Document findings and communicate decisions regarding utilization review outcomes to relevant stakeholders.
• Participate in appeals and peer review processes when necessary to resolve coverage disputes.
• Maintain up-to-date knowledge of healthcare regulations, insurance requirements, and clinical best practices.
• Assist in identifying opportunities for improving patient care efficiency and reducing unnecessary healthcare expenditures.

Skills:

The Utilization Review LPN uses clinical knowledge and critical thinking skills daily to analyze patient records and treatment plans, ensuring that care provided aligns with established guidelines. Effective communication skills are essential for collaborating with healthcare providers and insurance representatives to clarify clinical information and explain review decisions. Organizational skills help manage multiple cases simultaneously while maintaining accurate documentation and meeting deadlines. Familiarity with healthcare regulations and insurance policies enables the LPN to navigate complex coverage criteria and support compliance efforts. Additionally, proficiency with electronic medical records and review software streamlines the evaluation process, enhancing efficiency and accuracy in utilization review activities.