Temp Utilization Management Review Nurse LVN

Santa Clara Family Health Plan • San Jose, CA

387d • $72,385 - $108,578

About The Position

The Utilization Management Review Nurse (LVN) at Santa Clara Family Health Plan is responsible for conducting clinical reviews for inpatient and outpatient authorization requests. This role ensures compliance with state and federal regulations while assessing the medical necessity of services. The position requires collaboration with Medical Directors for potential denial considerations and involves drafting notifications and coordinating referrals for continuity of care.

Requirements

• Active California Board of Nursing Licensed Vocational Nurse License (LVN) without restriction.
• Minimum one year of licensed related health care experience.
• Knowledge of managed care principles and practices with emphasis in Utilization Management and/or Case Management.
• Ability to consistently meet accuracy and timeline requirements for regulatory compliance.
• Excellent communication skills for service to internal departments, members, and providers.

Nice To Haves

• One year of experience within a Managed Care Health Plan.
• Knowledge of MediCal and/or Medicare guidelines and regulations.
• Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria.

Responsibilities

• Conduct clinical review for authorization requests within regulatory turnaround requirements.
• Process authorization reviews using appropriate clinical criteria and guidelines.
• Draft and process timely notification of action letters for authorization determinations.
• Coordinate referrals to appropriate departments for member continuity of care needs.
• Maintain adherence to CMS and DHCS regulatory requirements.
• Facilitate processing of Letters of Agreement with non-contracted Providers for approved services.
• Perform other duties as required or assigned.

Benefits

• Competitive salary range of $72,385 - $108,578 per year.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed