Licensed Vocational Nurse; LVN Utilization Management & Inpatient Case Management

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Licensed Vocational Nurse (LVN) - Utilization Management & Inpatient Case Management

Licensed Vocational Nurse (LVN) - Utilization Management & Inpatient Case Management
Fully Remote Remote Worker - N/A

Full-time

The Licensed Vocational Nurse (LVN) - Utilization Management & Inpatient Case Management is responsible for supporting the delivery of high-quality, medically appropriate, cost-effective healthcare services to members within an Independent Practice Association (IPA).

This position primarily focuses on inpatient utilization management, concurrent review, inpatient case management, and coordination of transitions of care
, while also providing support for outpatient utilization management activities as operational needs require.

The LVN works collaboratively with hospital case managers, discharge planners, physicians, health plans, and internal clinical teams to monitor inpatient admissions, facilitate timely reviews, support appropriate levels of care, identify barriers to discharge, and coordinate services that promote safe transitions across care settings.

The ideal candidate has strong knowledge of managed care operations, Medicare Advantage requirements, inpatient authorization processes, and clinical review workflows. This position requires excellent clinical judgment within the LVN scope of practice, organizational skills, and the ability to work independently in a fully remote environment.

Budgeted Compensation: $65,000 - $85,000 Annually

• Perform daily concurrent reviews of hospitalized members to monitor clinical status, utilization of services, continued-stay needs, and discharge readiness.
• Review inpatient admissions, clinical documentation, progress notes, diagnostic results, treatment plans, and anticipated discharge dates.
• Apply established clinical review criteria, including MCG, Inter Qual, or other organization-approved guidelines, as appropriate to the LVN scope of practice and organizational policy.
• Monitor inpatient length of stay, identify potentially avoidable inpatient days, and communicate opportunities to improve care coordination and resource utilization.
• Collaborate with hospital utilization review departments, case managers, discharge planners, and attending physicians to obtain necessary clinical information.
• Identify cases requiring additional clinical review and elevate to an RN, Medical Director, or other designated licensed clinician in accordance with established protocols.
• Monitor and track inpatient admissions, transfers, continued stays, observation services, and discharges.
• Support timely completion of authorization and concurrent review workflows in accordance with applicable CMS, health plan, contractual, and organizational requirements.
• Identify potential quality-of-care concerns, barriers to treatment, and opportunities for early intervention.
• Maintain accurate and timely documentation of clinical reviews, communications, interventions, and case status within the organization's utilization management platform.
• Participate in interdisciplinary case discussions and complex case reviews as needed.
• Collaborate with hospital case managers and discharge planning teams to facilitate safe, appropriate, and timely transitions of care.
• Identify hospitalized members at increased risk for prolonged hospitalization, readmission, or complications following discharge.
• Monitor discharge planning activities and identify barriers involving post-acute placement, durable medical equipment (DME), home health, transportation, medications, or specialty services.
• Coordinate with internal care management teams to facilitate…