Job Description

Job Summary

The Utilization Review Nurse - LPN coordinates key components of the facility's utilization management program, including admission reviews, status validations, and documentation support. This role performs third-party criteria assessments to determine medical necessity, assists with denial and appeal activities, and supports efforts to reduce unnecessary readmissions. The Utilization Review Nurse - LPN may also contribute to quality assurance and resource management initiatives.

Essential Functions

• Reviews medical records to determine medical necessity for admission using established third-party criteria (e.g., MCG, InterQual).
• Validates admission status and identifies potential discrepancies in patient placement.
• Initiates provider queries to clarify documentation and support appropriate utilization.
• Participates in interdisciplinary team meetings to discuss patient care plans and discharge readiness.
• Supports the implementation of process improvement initiatives related to utilization management and readmission reduction.
• Escalates complex or unresolved cases to appropriate leadership or physician advisors.
• Maintains compliance with internal policies, payer requirements, and regulatory guidelines.
• Protects patient privacy and ensures security of Protected Health Information (PHI).
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

• 2-4 years of experience in a hospital or nursing home setting required

Knowledge, Skills and Abilities

• Strong written and oral communication skills.
• Demonstrates empathy, compassion, and professionalism in patient interactions.
• Proficient in utilization management processes, criteria sets, and managed care standards.
• Knowledge of healthcare informatics and Electronic Health Records (EHR) systems.
• Sound problem-solving and critical thinking skills.
• Excellent organizational and time management skills to manage competing priorities.

Licenses and Certifications

• LPN - Licensed Practical Nurse - State Licensure required or
• LVN - Licensed Vocational Nurse required