Licensed Practical Nurse (LPN) Utilization Review Jobs

LPN Utilization Review MDS Full-time
Confidential Healthcare Facility

Utilization Review (MDS) – RN/LPN

Confidential Healthcare Facility Valley Stream, NY
$90,000 - $125,000 / hour
Utilization Review (MDS) – RN/LPN Location: Valley Stream, New York Job Type: Full-Time Schedule: Hybrid (Onsite Required 4 Days per Week) Compensation: $90,000 – $125,000 annually (DOE) About the Role We are seeking an experienced Utilization Review (MDS) RN/LPN to support Skilled Nursing Facility (SNF) operations and ensure accurate clinical review, care coordination, and reimbursement optimization. This position plays a key role in managing utilization review activities, supporting MDS-related processes, and collaborating with interdisciplinary teams to achieve positive clinical and financial outcomes. The ideal candidate will possess a strong background in skilled nursing, utilization review, managed care, and reimbursement processes. Key Responsibilities Utilization Review & MDS Management Conduct utilization review activities for SNF residents to ensure appropriate level of care and reimbursement. Review admissions, continued stays, payer changes, and discharge planning activities. Coordinate prior authorizations, clinical updates, denials, reconsiderations, and appeals with managed care organizations. Monitor reimbursement opportunities and ensure compliance with payer guidelines and regulatory requirements. Collaborate with interdisciplinary teams to support care planning and clinical outcomes. Review and analyze MDS assessments for accuracy, completeness, and reimbursement optimization. Participate in utilization review meetings and daily census management activities. Ensure timely issuance and submission of denial notices, NOMNCs, and related documentation. Maintain detailed and accurate records of all utilization management activities. Qualifications Required Active and unrestricted RN or LPN license . Minimum 3 years of experience in Skilled Nursing Facilities (SNF), utilization review, MDS coordination, managed care, case management, or related healthcare settings. Strong understanding of: MDS processes and reimbursement methodologies Utilization review and utilization management Prior authorizations and payer requirements Denials management and appeals Medicare, Medicaid, and managed care reimbursement Experience working with EMR systems and insurance portals. Excellent organizational, communication, and problem-solving skills. Ability to manage multiple priorities in a fast-paced environment. Preferred RAC-CT, CPC, CPUR, CCM, or related certifications. Experience working within the New York healthcare market. Why Join Us? Competitive salary: $90,000 – $125,000 DOE Hybrid work schedule with strong work-life balance Opportunity to make a direct impact on patient outcomes and reimbursement success Collaborative interdisciplinary team environment Professional growth and advancement opportunities Stable and growing healthcare organization How to Apply If you are an experienced RN or LPN professional with expertise in Utilization Review, MDS, and managed care , we encourage you to apply and become part of a team dedicated to delivering exceptional patient care while ensuring operational excellence. Apply today to advance your healthcare career with a meaningful and impactful role. INDCONF3
LPN Utilization Review Full-time
Guthrie

LPN Utilization Management Reviewer - Case Management - Full Time

Guthrie Cortland, NY
$20.38 - $31.81 / hour
This position is eligible for up to $15,000.00 Sign on Bonus for those that are eligible. ($7,500.00 for those with less than one year of experience) Summary The LPN Utilization Management (UM) Reviewer, in collaboration with Care Coordination, Guthrie Clinic offices, other physician offices, and the Robert Packer Hospital Business Office, is responsible for the coordination of Utilization Management (UM) processes and requirements of prior authorization/certification for reimbursement of patient care services. The responsibilities include: - Facilitating communication between physician offices, payers, Care Coordination and other hospital departments as appropriate to obtain prior authorization required to meet contractual reimbursement requirements and to assist in ensuring generation of clean claims in a timely manner - Securing authorization as appropriate - Documenting payer authorization - Facilitating issue resolution with payer sources in collaboration with other hospital departments or clinic offices as appropriate - Demonstrating ongoing competence in payer requirements, as defined collaboratively with Patient Business Services and Care Coordination Additionally, the position works closely with the Care Coordination department to support data collection and aggregation associated with UM processes and operations. Experience Minimum of five years clinical experience in an acute health care setting. Must possess strong communication and organizational skills, be able to work independently and to complete work within specified time frames. Knowledge of health benefit plans and related UM requirements preferred. Experience with CPT/ICD coding, medical record or chart auditing, and experience in utilization management processes preferred. Knowledge of computer applications (such as Microsoft word processing and spreadsheets) desirable Education/License Current LPN licensure or eligibility for licensure required Essential Functions 1. Conducts validation of the authorization/certification process for elective short procedures and inpatient care services in collaboration with physician offices, hospital Business Office, Care Coordination and other hospital departments as appropriate.2. Ensures documentation and communication of authorizations and certifications as appropriate. 3. Performs routine admission and discharge notification according to payer requirements. 4. Assists to ensure compliance with documentation requirements and guidelines of third-party payers, regulatory and government agencies. 5. Develops and maintains collaborative relationships with members of the healthcare team. - Proactively researches case findings related to payer audits of UM decisions and prepares input for supporting documentation to complete the revenue cycle process, coordinates as necessary with the hospital Business Office, physician offices, Care Coordination, Medical Director and other hospital departments as appropriate.1. Serves as liaison with payers, hospital Business Office, physician offices, Care Coordination and other hospital departments as appropriate for resolution of issues or questions. 2. Collaborates with the hospital Business Office, physician offices, Care Coordination and other hospital departments as appropriate to track and monitor the status for denials and appeals. - Participates in performance improvement and educational activities.1. Serves as an educational resource to other members of the healthcare team with regards to changes in reimbursement, payers, and/or utilization requirements. 2. Participates in departmental long-range planning to meet the needs identified through utilization management activities. 3. Demonstrates appropriate problem solving and decision-making skills. 4. Maintains the required 8 hours of continuing education per year. Other Duties It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position. Pay Range $20.38-$31.81/hr Dependent on years of applicable experience.
LPN Utilization Review Full-time
Guthrie

LPN Licensed Practical Nurse - Utilization Mgmt Reviewer (Case Mgmnt) - Full Time

Guthrie Cortland, NY
$20.38 - $31.81 / hour
This position is eligible for up to $15,000.00 Sign on Bonus for those that are eligible. ($7,500.00 for those with less than one year of experience) Summary The LPN Utilization Management (UM) Reviewer, in collaboration with Care Coordination, Guthrie Clinic offices, other physician offices, and the Robert Packer Hospital Business Office, is responsible for the coordination of Utilization Management (UM) processes and requirements of prior authorization/certification for reimbursement of patient care services. The responsibilities include: - Facilitating communication between physician offices, payers, Care Coordination and other hospital departments as appropriate to obtain prior authorization required to meet contractual reimbursement requirements and to assist in ensuring generation of clean claims in a timely manner - Securing authorization as appropriate - Documenting payer authorization - Facilitating issue resolution with payer sources in collaboration with other hospital departments or clinic offices as appropriate - Demonstrating ongoing competence in payer requirements, as defined collaboratively with Patient Business Services and Care Coordination Additionally, the position works closely with the Care Coordination department to support data collection and aggregation associated with UM processes and operations. Experience Minimum of five years clinical experience in an acute health care setting. Must possess strong communication and organizational skills, be able to work independently and to complete work within specified time frames. Knowledge of health benefit plans and related UM requirements preferred. Experience with CPT/ICD coding, medical record or chart auditing, and experience in utilization management processes preferred. Knowledge of computer applications (such as Microsoft word processing and spreadsheets) desirable Education/License Current LPN licensure or eligibility for licensure required Essential Functions 1. Conducts validation of the authorization/certification process for elective short procedures and inpatient care services in collaboration with physician offices, hospital Business Office, Care Coordination and other hospital departments as appropriate.2. Ensures documentation and communication of authorizations and certifications as appropriate. 3. Performs routine admission and discharge notification according to payer requirements. 4. Assists to ensure compliance with documentation requirements and guidelines of third-party payers, regulatory and government agencies. 5. Develops and maintains collaborative relationships with members of the healthcare team. - Proactively researches case findings related to payer audits of UM decisions and prepares input for supporting documentation to complete the revenue cycle process, coordinates as necessary with the hospital Business Office, physician offices, Care Coordination, Medical Director and other hospital departments as appropriate.1. Serves as liaison with payers, hospital Business Office, physician offices, Care Coordination and other hospital departments as appropriate for resolution of issues or questions. 2. Collaborates with the hospital Business Office, physician offices, Care Coordination and other hospital departments as appropriate to track and monitor the status for denials and appeals. - Participates in performance improvement and educational activities.1. Serves as an educational resource to other members of the healthcare team with regards to changes in reimbursement, payers, and/or utilization requirements. 2. Participates in departmental long-range planning to meet the needs identified through utilization management activities. 3. Demonstrates appropriate problem solving and decision-making skills. 4. Maintains the required 8 hours of continuing education per year. Other Duties It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position. Pay Range $20.38-$31.81/hr Dependent on years of applicable experience.
LPN Utilization Review Telehealth Full-time
CVS Health

Utilization Management - LPN

CVS Health
$22.40 - $48.67 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilizes clinical skills to support the coordination, documentation and communication of medical services and benefit administration determinations. Leverages Licensed Practical Nurse and Licensed Vocational Nurse (LPN/LVN) licenses and experience to ensure sound medical care, chart documentation, and patient follow-up. Required Qualifications Licensed Practical Nurse Basic awareness of problem solving and decision making skills. Basic awareness of digital literacy skills. Basic knowledge of medical terminology. Ability to deal tactfully with customers and community. Ability to handle sensitive information ethically and responsibly. Ability to consider the relative costs and benefits of potential actions to choose the most appropriate option. Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients. Preferred Qualifications Bachelor's degree preferred Specialized training/relevant professional qualification Education Bachelor's degree preferred/specialized training/relevant professional qualification. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $22.40 - $48.67 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/03/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.