Utilization Review Spec LVN Remote - Kelsey Seybold Clinics - Remote

Join Kelsey-Seybold Clinic, part of Optum.

The Utilization Review Specialist (LVN) conducts medical reviews, verifies benefits, and applies criteria to determine medical necessity for health care services requiring authorization prior to rendering services to members. The specialist serves as a liaison in reviewing requests for medical and surgical procedures, services, and admissions, and communicates with providers to ensure timely service decisions. The role also involves completing and reviewing denial letters in accordance with Texas Department of Insurance (TDI) and CMS requirements, acting as the primary contact for add‑on procedures at the KS Ambulatory Surgery Center (ASC), supporting quality assurance initiatives, and adapting to changes in policies and procedures.

• Conduct medical reviews and benefit verification.
• Determine medical necessity for services needing prior authorization.
• Serve as liaison for reviewing medical and surgical procedure requests.
• Communicate with providers to gather necessary information for reviews.
• Coordinate with the Grievance and Appeals Department for Medicare Advantage appeals.
• Complete and review denial letters per TDI and CMS guidelines.
• Act as the primary point of contact for add‑on procedures at the KS ASC.
• Support utilization review quality assurance initiatives, including mock audits.
• Adapt to changes in policies, procedures, and new responsibilities as required.

• Licensed Vocational Nurse.
• Active Texas RN license or multistate compact RN license.
• 5+ years of utilization review experience at a health plan, ACO, IPA, or provider group.
• Knowledge of HMO, PPO, and POS insurance plans.
• Consistent and prompt attendance at employer worksite is an essential job requirement.

• Continuous Education Unit (CEU) maintenance required.
• Certification in area of specialization.
• Experience obtaining authorizations and pre‑certification for medical services with insurance companies.
• Proven excellent verbal, communication, and organizational skills.
• Bilingual ability.
• Active driver’s license.

If you are located in Texas, you will have the flexibility to work remotely. All remote employees must adhere to United Health Group's Telecommuter Policy.

The hourly pay for this role ranges from $20.38 to $36.44 per hour based on full‑time employment. Salary and benefits are determined by local labor market factors, education, experience, and certifications. Benefits include a comprehensive benefits package, incentive and recognition programs, equity stock purchase options, and 401(k) contributions (subject to eligibility).

Optum Care is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

Optum Care is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.