Part-Time, UM LVN

The Utilization Management (UM) LVN is responsible for performing clinical review activities to support the prior authorization, concurrent review, retrospective review, and care coordination processes. Working within EZCAP and other clinical systems, the UM LVN applies evidence-based criteria and health plan guidelines to ensure medically necessary, appropriate, timely, and cost-effective healthcare services while maintaining compliance with CMS, DMHC, NCQA, and delegated health plan requirements.

The UM LVN collaborates with physicians, providers, hospitals, case managers, and interdisciplinary staff to facilitate quality patient care and efficient utilization of healthcare resources.

• Perform clinical review of prior authorization requests using approved clinical criteria (MCG, Inter Qual, CMS, Health Plan guidelines, etc.).
• Review outpatient, inpatient, DME, imaging, therapy, home health, and specialty referrals.
• Determine whether requests meet medical necessity criteria within LVN scope of practice.
• Identify cases requiring Medical Director review.
• Monitor turnaround times to ensure compliance with regulatory requirements.
• Prioritize expedited and urgent authorization requests.

• Monitor inpatient admissions and length of stay.
• Coordinate discharge planning with Case Management.
• Collaborate with hospitals regarding continued medical necessity.

• Document complete and accurate clinical reviews in EZCAP.
• Record medical necessity rationale.
• Maintain detailed authorization notes.
• Ensure documentation supports regulatory and audit requirements.

• Contact provider offices to obtain additional clinical documentation.
• Communicate approved services when appropriate.
• Educate providers regarding UM requirements.
• Work closely with:
  • Medical Directors
  • UM Coordinators
  • Case Managers
  • Provider Relations
  • Claims
  • Health Plans
  • Hospitals
  • Skilled Nursing Facilities
  • Home Health Agencies

Maintain compliance with:

• NCQA UM Standards
• Organizational UM Policies
• HIPAA Privacy Regulations

• Participate in internal audits.
• Assist with corrective action plans.
• Identify workflow improvements.
• Participate in UM Committee initiatives.

• Complete clinical review documentation.
• Document medical necessity findings.
• Monitor work queues.
• Ensure timely processing of referrals.

Knowledge of:

• Medical terminology
• Disease processes
• Managed Care principles
• Prior Authorization process
• Concurrent Review
• Clinical documentation
• CMS requirements
• HIPAA regulations
• NCQA standards

• Graduate of an accredited Vocational Nursing Program.

• Current California Licensed Vocational Nurse (LVN) license in good standing.

• Minimum 2 years clinical nursing experience.
• Minimum 1 year Utilization Management experience preferred.
• Experience in managed care preferred.
• Experience with Medicare Advantage preferred.

Experience with:

• EZCAP
• EZNET
• MCG or Inter Qual Criteria
• Medi-Cal Managed Care
• Delegated Medical Groups
• Prior Authorization
• Concurrent Review
• Case Management

• Strong clinical assessment skills
• Critical thinking
• Time management
• Organizational skills
• Professional communication
• Ability to prioritize multiple requests
• Team collaboration

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

• Health Coverage You Can Count On
  :
  Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable
  :
  Discounted vision and dental premiums to help keep you healthy from head to toe.
• Smart Spending
  : FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance
  :
  Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
• Career Development
  :
  Tuition reimbursement to support your education and growth.
• Team Fun
  :
  Paid company outings and lunches because we work hard, but we also know how to have fun!