Utilization Nurse

The Utilization Review Nurse - LPN coordinates key components of the facility's utilization management program, including admission reviews, status validations, and documentation support. This role performs third-party criteria assessments to determine medical necessity, assists with denial and appeal activities, and supports efforts to reduce unnecessary readmissions. The Utilization Review Nurse - LPN may also contribute to quality assurance and resource management initiatives.

Essential Functions

Reviews medical records to determine medical necessity for admission using established third-party criteria (e.g., MCG, InterQual). Validates admission status and identifies potential discrepancies in patient placement. Initiates provider queries to clarify documentation and support appropriate utilization. Participates in interdisciplinary team meetings to discuss patient care plans and discharge readiness. Supports the implementation of process improvement initiatives related to utilization management and readmission reduction. Escalates complex or unresolved cases to appropriate leadership or physician advisors. Maintains compliance with internal policies, payer requirements, and regulatory guidelines. Protects patient privacy and ensures security of Protected Health Information (PHI). Performs other duties as assigned. Maintains regular and reliable attendance. Complies with all policies and standards. Qualifications

2-4 years of experience in a hospital or nursing home setting required Knowledge, Skills and Abilities

Strong written and oral communication skills. Demonstrates empathy, compassion, and professionalism in patient interactions. Proficient in utilization management processes, criteria sets, and managed care standards. Knowledge of healthcare informatics and Electronic Health Records (EHR) systems. Sound problem-solving and critical thinking skills. Excellent organizational and time management skills to manage competing priorities. Licenses and Certifications

LPN - Licensed Practical Nurse - State Licensure required or LVN - Licensed Vocational Nurse required