LPN Utilization Review Specialist

5 days ago


Birmingham, Alabama, United States viva health Full time
About the Role

We are seeking an experienced LPN to join our team as a Utilization Review Specialist. In this role, you will be responsible for reviewing requests for prior authorization of outpatient and inpatient services for Commercial and Medicare product lines.

Key Responsibilities
  • Utilize evidenced-based criteria and/or VIVA HEALTH internally developed criteria to review provider requests for medical necessity.
  • Coordinate authorizations including specialist referrals, outpatient therapies, surgeries, durable medical equipment (DME), and pharmacy services both internally and externally.
  • Ensure services authorized are covered benefits and medically necessary by citing relevant criteria, certificate of coverage, or evidence of coverage.
  • Forward potential denials to the Medical Director or designee and any other services requiring administrative review.
Requirements
  • High School Diploma or GED
  • 1-3 years' experience as an LPN in a hospital setting, private physician or ancillary vendor's office
  • Current LPN License in good standing with the State of Alabama Board of Nursing
  • Licensed Practical Nurse Certification
Preferred Qualifications
  • Utilization review or precertification experience utilizing InterQual or Milliman guidelines
  • Relevant customer service or call center experience

Salary Range: $55,000 - $65,000 per year based on experience and qualifications.



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