This role focuses on reviewing medical information and supporting utilization management decisions for members, with work centered on assessing clinical appropriateness and coordinating prior authorization activities. The clinician also helps interpret documentation, apply coverage criteria, and communicate determinations across the care team. PST availability is preferred for scheduling flexibility.
Key Responsibilities
- Review medical records and authorization requests for clinical appropriateness.
- Apply established coverage criteria and utilization management guidelines.
- Coordinate prior authorization workflows and support case processing.
- Communicate clinical findings and determination status with internal teams.
- Document review outcomes and maintain accurate case records.
- Support care coordination efforts related to member services and medical review.
Required
- Active LVN or LPN license.
- Experience in medical review, utilization management, or a related clinical support role.
Preferred
- Availability during Pacific Standard Time hours.