Time Type: Full time
Department: Senior Care Options (SCO)
All Locations: 10 Gove Street - Taylor Building
Position Summary: The LPN UM Reviewer supports the Utilization Management team by reviewing authorization requests, monitoring medical necessity criteria, coordinating care with providers, and ensuring compliance with health plan and regulatory requirements.
Key Responsibilities- Review prior authorization requests for medical services, medications, DME, home health, and other healthcare services.
- Apply established clinical guidelines and medical necessity criteria when evaluating requests.
- Gather and review clinical documentation from providers and facilities.
- Communicate with providers, care managers, and interdisciplinary team members regarding authorization decisions and required documentation.
- Escalate complex cases or requests that require RN or Medical Director review.
- Document determinations and activities accurately in utilization management systems.
- Monitor authorization turnaround times and regulatory compliance requirements.
- Support appeals, reconsiderations, and grievance processes as assigned.
- Participate in quality improvement and audit activities.
Qualifications- Current, unrestricted LPN license.
- Experience in managed care, utilization management, case management, prior authorization, or clinical review preferred.
- Knowledge of medical terminology, healthcare regulations, and clinical documentation.
- Strong organizational, communication, and computer skills.
- Ability to work independently and manage multiple priorities.
Preferred Experience- Experience with Medicare, Medicaid, SCO, One Care, or managed care programs.
- Familiarity with InterQual, MCG, or other medical necessity criteria tools.
- Experience using EMRs and authorization management systems.
Salary: Starting at $33/hr up to $48/hr based on experience 
