Job Description:
• Initiate referrals and support care coordination workflows by gathering required clinical information and confirming benefit completeness under established UM procedures.
• Perform structured clinical reviews using preset criteria and templates, escalating any findings requiring RN/Medical Director interpretation.
• Consult with supervising RN or Medical Director when requests involve clinical questions, exceptions, or scenarios requiring higher level clinical judgment.
• Assist nonclinical staff by clarifying clinical documentation, interpreting request elements within LPN practice parameters.
• Apply approved medical appropriateness criteria and contractual eligibility information to support intake validation and preparation of clinical review materials.
• Document all review activities in required UM systems with accuracy, completeness, and adherence to regulatory documentation standards.
• Communicate with providers, members, and internal teams regarding missing documentation, process requirements, and case status.
• Participate in quality improvement, compliance activities, and competency requirements tied to UM program standards.
Requirements:
• Licensed Practical Nurse (LPN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
• 1-2 years - Clinical experience required.
• Knowledge of community resources, benefits, and service authorization processes.
• Familiarity with care management frameworks and regulatory requirements.
• High attention to detail with the ability to document accurately and meet regulatory standards (NCQA, URAC, CMS).
Benefits:
• Health insurance
• 401(k) matching
• Flexible work hours
• Paid time off
• Remote work options