LPN/LVN Utilization Management Reviewer - Remote Opportunity

We are seeking a highly skilled and experienced LPN/LVN Utilization Management Reviewer to join our team at Employelevate, a leading provider of healthcare solutions. As a Utilization Management Reviewer, you will play a critical role in evaluating the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities under the provisions of our clients' benefits plans.

In this remote, full-time position, you will utilize your clinical expertise and strong analytical skills to conduct timely clinical decision reviews, apply established criteria, and communicate results to healthcare providers and members. Your expertise will help ensure that our clients meet CMS compliance standards and provide high-quality care to their members.

Key Responsibilities:

• Conduct timely clinical decision reviews for services requiring prior authorization, including Durable Medical Equipment/Services, Long Term Services and Supports (LTSS), and Home Health (HH)
• Apply established criteria, such as InterQual, to determine medical necessity of services
• Communicate results of reviews verbally, in the medical record, and through official written notification to healthcare providers and members
• Provide decision-making guidance to clinical teams on service planning as needed
• Collaborate with clinicians, medical staff, and peer reviewers to facilitate escalated reviews
• Maintain accurate documentation of clinical decisions and ensure consistency in applying policy

Requirements:

• Associate degree in Nursing or related field
• Current, valid Massachusetts clinical license in good standing
• 3+ years of combined clinical and utilization management experience
• Strong analytical, communication, and interpersonal skills
• Ability to work independently and as part of a team
• Comfort working in a remote environment with a secure, private workspace and reliable internet connection

What We Offer:

• Competitive salary and benefits package, including medical, dental, vision, life insurance, and 401K with employer contribution
• Opportunity to work with a leading healthcare solutions provider
• Remote work arrangement with flexible scheduling
• Professional development and growth opportunities
• Collaborative and dynamic work environment

How to Apply:

If you are a motivated and experienced LPN/LVN with a passion for utilization management, we encourage you to apply for this exciting opportunity. Please submit your application, including your resume and a cover letter, to Apply to this Job.

Employelevate is an Equal Opportunity Employer/Vet/Disability. We are committed to diversity and inclusion in the workplace and welcome applications from qualified candidates.