LVN Utilization Review (In Office) at NEOGEN CARE – Los Angeles, California

Founded in 2014 in San Francisco Bay Area, Neogen Care’s vision is to transform the way healthcare is provided and received by patients in the home. We strive to improve the quality of your life with our team of specially trained nurses, therapists and reliable caregivers. As a leading provider of medical and non-medical home care services we will continue to contribute to the future of our community and support healthy lifestyles.

Neogen Care is a will established Home Health Care agency with patients throughout the California Bay Area, greater Los Angeles, Ventura, San Diego, Orange, San Bernardino and Riverside counties. Our agency is fully partnered with Kaiser Permanente as our primary client. We share Kaiser's culture and vision to provide patient centered care with a strong focus on quality throughout our patient care operations. We have a strong compliance history of successfully passing CHAP surveys and client audits; and operate with ethics at the center of our Core Values.

We are looking for a Utilization Review Licensed Vocational Nurse to join our fast-growing team. Become part of a notable company and help us achieve our goals!

About the Role:

The LVN Utilization Review role is pivotal in ensuring that patient care services are delivered efficiently and in accordance with established clinical guidelines and regulatory requirements. This position involves the thorough evaluation of medical records and treatment plans to determine the appropriateness, necessity, and efficiency of healthcare services provided to patients. The LVN Utilization Reviewer collaborates closely with healthcare providers, insurance companies, and case managers to facilitate optimal patient outcomes while managing healthcare costs. This role requires a keen eye for detail, strong clinical knowledge, and the ability to interpret complex medical information to support decision-making processes. Ultimately, the LVN Utilization Reviewer helps maintain high standards of care and compliance within healthcare organizations across the United States.

Minimum Qualifications:

• Current and valid Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license in the United States.
• Minimum of 2 years clinical nursing experience, preferably in acute care or related healthcare settings.
• Basic understanding of medical terminology, clinical procedures, and healthcare documentation.
• Familiarity with utilization review processes and healthcare regulations such as Medicare and Medicaid guidelines.
• Strong written and verbal communication skills.

Preferred Qualifications:

• Experience in utilization review, case management, or healthcare quality assurance.
• Certification in Utilization Review or Case Management (e.g., Certified Professional in Utilization Review - CPUR).
• Proficiency with electronic medical records (EMR) systems and healthcare data management software.
• Knowledge of insurance payer policies and healthcare reimbursement methodologies.
• Minimum Associate degree in Nursing
• Prior home health experience and strong knowledge with wounds and wound care treatments

Responsibilities:

• Review patient medical records and clinical documentation to assess the necessity and appropriateness of healthcare services.
• Evaluate treatment plans and healthcare interventions against established clinical guidelines and payer policies.
• Communicate effectively with physicians, nurses, case managers, and insurance representatives to clarify clinical information and resolve discrepancies.
• Prepare detailed reports and documentation to support utilization review decisions and ensure compliance with regulatory standards.
• Monitor ongoing patient care to identify opportunities for care coordination, discharge planning, and resource optimization.

Skills:

The LVN Utilization Reviewer applies clinical nursing knowledge daily to analyze patient records and treatment plans critically, ensuring that care provided aligns with best practices and payer requirements. Strong communication skills are essential for collaborating with multidisciplinary teams and negotiating with insurance representatives to facilitate approvals and resolve issues. Attention to detail and analytical skills are used to identify inconsistencies or gaps in documentation that could impact patient care or reimbursement. Familiarity with healthcare regulations and utilization review standards guides the decision-making process to maintain compliance and optimize resource use. Additionally, proficiency with electronic medical records and data management tools supports efficient documentation, reporting, and tracking of utilization review activities.