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Role Description

We are seeking a Licensed Vocational Nurse (LVN) to provide temporary Utilization Review (UR) support during a leave of absence. The Utilization Review Nurse is responsible for reviewing medical records and treatment requests to determine the medical necessity of services based on evidence-based guidelines and workers’ compensation regulations.

• Review medical records and treatment requests to determine medical necessity based on evidence-based guidelines and best practices.
• Identify diagnoses and evaluate treatment plans against appropriate care algorithms.
• Apply guidelines such as MTUS, ACOEM, MCG, ODG, and state-specific treatment standards during case review.
• Identify potential over-utilization and collaborate with providers when treatment modifications are appropriate.
• Refer cases requiring non-certification to physician peer reviewers.
• Coordinate peer-to-peer discussions between treating providers and reviewing physicians when necessary.
• Authorize appropriate inpatient and outpatient procedures.
• Communicate utilization review determinations to claims examiners, providers, attorneys, and other stakeholders within required regulatory timelines.
• Summarize medical records and present case recommendations to physician advisors or peer reviewers.
• Identify cases requiring medical case management and recommend referrals through the supervisor.
• Collaborate with clients, claims teams, nurse case managers, and supervisors to ensure effective case management.
• Support oversight of assigned non-clinical staff tasks when required.
• Assist with notification processes for treatment non-certifications issued by physician reviewers.

Qualifications

• Licensed Vocational Nurse (LVN)
• Minimum 3 years of clinical experience.
• Strong understanding of medical terminology and clinical documentation.
• Ability to manage multiple cases and priorities in a fast-paced environment.
• Strong organizational, time management, and communication skills.
• California Workers’ Compensation experience.
• Utilization Review or Managed Care experience.
• Familiarity with California Workers’ Compensation regulations.
• Completion of IEA CA10 certification within one year of employment.
• Strong attention to detail and analytical skills.
• Ability to multitask and adapt to changing priorities.
• Excellent organizational and time management skills.
• Ability to collaborate with providers, clients, and internal teams.
• Self-motivated with the ability to work independently in a remote environment.

Requirements

• May on occasion be exposed to loud sounds and distracting noise levels, such as from office equipment.
• The ability to lift up to 30lbs.
• Use of computers and technology.

Benefits

• Health care and 401(k) savings plans.