UM Nurse (LVN)

Position Overview

This role supports clinical operations by conducting timely and thorough reviews of service authorization requests to determine medical necessity and compliance with health plan benefits and clinical guidelines. The selected candidate will ensure members receive appropriate and timely care while supporting regulatory and quality standards.

Key Responsibilities

• Review and triage service requests for medical necessity and timeliness.
• Apply clinical guidelines and benefit plans to develop recommendations.
• Present cases to the Medical Director when further clinical review is warranted.
• Communicate outcomes with providers and members in accordance with regulations.
• Ensure accurate documentation in internal systems per departmental policies.
• Refer members to California Childrens Services (CCS), Tri-Counties Regional Center (TCRC), or other care coordination programs.
• Identify and escalate quality-of-care concerns.
• Participate in cross-functional meetings and emergency response programs as assigned.

Required Qualifications

• Graduate of an accredited LVN program.
• Active, unrestricted California LVN license.
• Knowledge of UM criteria: MCG, InterQual, Medi-Cal, Medicare.
• Proficiency in Microsoft Word and documentation systems.
• Bilingual English/Spanish preferred.
• Experience with HIPAA, NCQA, or JCAHO standards.