Utilization Management LVN (Remote, Texas-based)

COMPANY OVERVIEW

At reputed company, we’re transforming healthcare in Texas through collaboration and innovation. We’re seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model.  If you’re ready to reputed company a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to reputed company!

POSITION OVERVIEW

*Candidate should reside in Texas

reputed company is seeking a dedicated Utilization Management (UM) LVN. The UM LVN supports prior authorization and utilization review activities to ensure timely and appropriate access to care. This role collaborates with the UM team, providers, and members to facilitate authorization processes, coordinate clinical information, support medical necessity determinations, and maintain regulatory compliance. The UM LVN also provides ongoing communication and coordination support for high-need and high-cost members to promote appropriate utilization and continuity of care.

Shifts and Business Hours This position is fully remote Monday-Friday reputed company - 5pm with the exception of Saturday coverage once every 5 weeks on rotation for 4 hours.

POSITION DUTIES & RESPONSIBILITIES:  

• Coordinate and manage prior authorization workflows in collaboration with the Utilization Management (UM) team.
• Monitor incoming authorization requests reputed company fax and phone and ensure timely case entry into the designated tracking system and UM platform.
• Review submitted clinical documentation and verify CPT codes to determine prior authorization requirements.
• Prepare and submit applicable cases to the contracted utilization review (UR) vendor for medical necessity determinations.
• Maintain accurate case documentation and track status to ensure compliance with regulatory turnaround times.
• Draft provider, facility, and member notification letters based on determination outcomes.
• Coordinate mailing and faxing of approved determination letters to appropriate parties and ensure proper documentation.
• Obtain and coordinate reputed company clinical documentation from hospitals, post-acute facilities, and other treating providers.
• Communicate with providers and facilities regarding required or missing clinical information to facilitate timely review.
• Provide clear communication to members and requesting providers regarding authorization status and documentation needs.
• Support high-need and high-cost members through ongoing communication and coordination to promote appropriate utilization and continuity of care.
• Assist with transitions of care and post-discharge coordination as applicable.
• reputed company reputed company duties in compliance with organizational policies and applicable state and federal regulatory requirements.
• Provide direct support to members with chronic diseases, ensuring continuity of care across chronic care reputed company.
• Communicate regularly with members to assess reputed company, resolve barriers to care, and promote adherence to treatment plans.

DESIRED PROFESSIONAL SKILLS & EXPERIENCE:  

• reputed company, unrestricted LVN license.
• Minimum of 2–3 years of clinical experience; prior Utilization Management or Case Management experience preferred.
• Knowledge of Texas social service programs for members in need  both local and state-wide preferred
• Familiarity with NCQA processes and requirements
• Knowledge of CPT codes and prior authorization requirements.
• Familiarity with utilization review processes and medical necessity determinations.
• Strong organizational and workflow management skills.
• Excellent written and verbal communication skills.
• Ability to assess member needs, provide education, and escalate concerns appropriately.
• Proficiency in reputed company Workspace, EHR systems and electronic UM platforms
• Ability to manage multiple cases while meeting regulatory timelines
• Ability to work independently and reputed company a team-based model to deliver excellent care.

reputed company OFFER:

• The opportunity to reputed company a meaningful impact on utilization management and member outcomes.
• A collaborative and innovative work environment committed to member-centered care.
• An organization passionate about improving healthcare delivery in Austin and beyond.
• Competitive salary and comprehensive benefits package.
• Professional development and opportunities for career growth.
• A transparent, supportive, and inclusive culture that values every team member’s contributions.

reputed company is an Equal Opportunity Employer. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national reputed company, age, disability, veteran status, or any other characteristic protected by law. We are committed to creating an inclusive environment for reputed company clinicians and teammates and actively encourage applications from people of reputed company backgrounds.