Prior Authorization LVN

JOB SUMMARY

The Prior Authorization Nurse (LVN) is responsible for performing clinical review and evaluation of authorization requests to ensure medical necessity, appropriate utilization of healthcare services, and compliance with regulatory and health plan requirements. This role conducts prospective, concurrent, and retrospective review of medical services including specialty care, diagnostic procedures, elective admissions, post-acute services, and out-of-network referrals. The Prior Authorization LVN collaborates with providers, health plans, and internal clinical teams to support timely care coordination while ensuring adherence to CMS, NCQA, and organizational guidelines. The position serves as a clinical resource to Prior Authorization Coordinators and supports efficient utilization management operations. 

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High School Diploma or equivalent and graduation from an accredited Vocational Nursing Program.  

Experience

Minimum: At least one year of   clinical experience in a healthcare setting. Basic knowledge of medical terminology, utilization management processes, and clinical care practices.

Preferred: Two or more years of utilization management, prior authorization, case management, or managed care experience. Experience working in an MSO, IPA, health plan, or medical group environment. Experience using Milliman Care Guidelines (MCG), InterQual, or similar criteria tools. Knowledge of ICD-10, CPT, and HCPCS coding. Experience with electronic health record and utilization management systems.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Current, active, unrestricted California LVN license required.

Skills, Knowledge & Abilities

· Knowledge of utilization management principles, medical necessity criteria, and managed care processes.

· Understanding of clinical documentation and healthcare delivery systems.

· Familiarity with regulatory requirements including NCQA, CMS, and HIPAA.

· Strong verbal and written communication skills.

· Ability to effectively communicate with physicians, providers, and interdisciplinary teams.

· Ability to provide clear and professional clinical guidance.

· Ability to review and interpret clinical information and apply established criteria.

· Strong organizational and prioritization skills.

· Ability to manage multiple tasks and deadlines efficiently.

· Proficiency in Microsoft Office (Word, Excel, Outlook).

· Ability to use electronic medical records and authorization systems.

· Ability to learn and adapt to new software and technology.

· Strong attention to detail and accuracy.

· Ability to maintain confidentiality and professionalism.

· Ability to work independently and as part of a team.

PHYSICAL, MENTAL  & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented of those that must  be met by an employee to successfully perform the essential functions of this job. Prolonged sitting, typing, and computer work. Occasional standing, walking, bending, and reaching. Ability to lift up to 20 pounds occasionally. Ability to concentrate for extended periods while reviewing clinical documentation. Ability to manage multiple priorities in a fast-paced environment. Ability to exercise sound clinical judgment and decision-making. Primarily office-based or hybrid work environment. Frequent interaction with healthcare providers and internal staff via phone and electronic communication. Low to moderate noise level consistent with office environment.