Licensed Vocational Nurse (LVN) – Utilization Management & Inpatient Case Management

Position Summary

The Licensed Vocational Nurse (LVN) – Utilization Management & Inpatient Case Management is responsible for supporting the delivery of high-quality, medically appropriate, cost-effective healthcare services to members within an Independent Practice Association (IPA).

This position primarily focuses on inpatient utilization management, concurrent review, inpatient case management, and coordination of transitions of care, while also providing support for outpatient utilization management activities as operational needs require.

The LVN works collaboratively with hospital case managers, discharge planners, physicians, health plans, and internal clinical teams to monitor inpatient admissions, facilitate timely reviews, support appropriate levels of care, identify barriers to discharge, and coordinate services that promote safe transitions across care settings.

The ideal candidate has strong knowledge of managed care operations, Medicare Advantage requirements, inpatient authorization processes, and clinical review workflows. This position requires excellent clinical judgment within the LVN scope of practice, organizational skills, and the ability to work independently in a fully remote environment.

Budgeted Compensation: $65,000 - $85,000 Annually

Essential Duties and Responsibilities

1. Inpatient Utilization Management & Concurrent Review (Primary Responsibility)

• Perform daily concurrent reviews of hospitalized members to monitor clinical status, utilization of services, continued-stay needs, and discharge readiness.
• Review inpatient admissions, clinical documentation, progress notes, diagnostic results, treatment plans, and anticipated discharge dates.
• Apply established clinical review criteria, including MCG, InterQual, or other organization-approved guidelines, as appropriate to the LVN scope of practice and organizational policy.
• Monitor inpatient length of stay, identify potentially avoidable inpatient days, and communicate opportunities to improve care coordination and resource utilization.
• Collaborate with hospital utilization review departments, case managers, discharge planners, and attending physicians to obtain necessary clinical information.
• Identify cases requiring additional clinical review and escalate to an RN, Medical Director, or other designated licensed clinician in accordance with established protocols.
• Monitor and track inpatient admissions, transfers, continued stays, observation services, and discharges.
• Support timely completion of authorization and concurrent review workflows in accordance with applicable CMS, health plan, contractual, and organizational requirements.
• Identify potential quality-of-care concerns, barriers to treatment, and opportunities for early intervention.
• Maintain accurate and timely documentation of clinical reviews, communications, interventions, and case status within the organization's utilization management platform.
• Participate in interdisciplinary case discussions and complex case reviews as needed.

2. Inpatient Case Management & Discharge Planning

• Collaborate with hospital case managers and discharge planning teams to facilitate safe, appropriate, and timely transitions of care.
• Identify hospitalized members at increased risk for prolonged hospitalization, readmission, or complications following discharge.
• Monitor discharge planning activities and identify barriers involving post-acute placement, durable medical equipment (DME), home health, transportation, medications, or specialty services.
• Coordinate with internal care management teams to facilitate post-discharge outreach and continuity of care.
• Assist with arranging medically necessary post-acute services in collaboration with treating providers, health plans, and contracted providers.
• Support coordination of transitions to skilled nursing facilities, home health services, rehabilitation facilities, and other appropriate levels of care.
• Communicate anticipated discharge dates and outstanding needs to appropriate internal and external stakeholders.
• Identify members who may benefit from complex case management, chronic disease management, or additional care coordination services.
• Facilitate timely referrals to RN case managers, social workers, or other appropriate clinical resources.
• Assist with post-discharge follow-up activities, including appointment coordination, medication-related concerns, and identification of potential gaps in care.
• Support initiatives designed to reduce avoidable hospitalizations, prevent readmissions, and improve member outcomes.

3. Outpatient Utilization Management

• Provide outpatient utilization management support as needed to maintain operational coverage and meet departmental turnaround-time requirements.
• Review outpatient authorization requests for completeness, clinical documentation, and applicable benefit or authorization requirements.
• Perform clinical screening of outpatient services using approved clinical guidelines and established workflows within the LVN scope of practice.
• Support authorization processing for specialist consultations, diagnostic imaging, outpatient procedures, therapies, DME, and other covered services.
• Identify requests requiring additional clinical review and refer them to the appropriate RN or Medical Director.
• Assist with urgent and routine authorization requests, ensuring compliance with applicable regulatory and contractual timelines.
• Communicate with providers, health plans, and internal authorization teams to obtain additional information and resolve outstanding requests.
• Maintain accurate documentation of authorization activities, determinations made by authorized decision-makers, and provider communications.
• Provide cross-coverage for outpatient utilization management staff during periods of increased volume, absences, or operational need.

4. Weekend & After-Hours On-Call Coverage

• Participate in a rotating weekend and after-hours on-call schedule to support continuity of inpatient utilization management and case management operations.
• Monitor and respond to time-sensitive inpatient notifications, authorization requests, and care coordination needs during assigned coverage periods.
• Communicate with hospitals, providers, and health plans regarding urgent clinical or operational issues.
• Escalate complex clinical cases, potential adverse determinations, and other matters requiring higher-level clinical review to the appropriate RN, Medical Director, or designated leadership.
• Support urgent discharge coordination and transitions of care when necessary.
• Ensure appropriate documentation and handoff of cases requiring follow-up during regular business hours.
• Maintain responsiveness and availability during assigned on-call periods in accordance with departmental expectations.
• Follow organizational policies regarding on-call scheduling, response times, timekeeping, and compensation.

5. Regulatory Compliance, Quality & Documentation

• Maintain compliance with applicable CMS, Medicare Advantage, California Department of Managed Health Care (DMHC), health plan, and organizational requirements.
• Follow established utilization management policies, clinical review protocols, and escalation procedures.
• Support compliance with applicable NCQA standards and organizational quality improvement initiatives.
• Ensure clinical documentation is complete, accurate, timely, and consistent with internal standards.
• Protect member confidentiality and comply with HIPAA and applicable privacy and information security requirements.
• Identify and escalate potential quality-of-care concerns, utilization trends, and regulatory compliance issues.
• Participate in internal audits, quality improvement projects, and process improvement initiatives.
• Support departmental efforts to improve authorization turnaround times, reduce avoidable inpatient days, and strengthen care coordination.

Scope of Practice & Clinical Oversight

The LVN performs assigned duties in accordance with the California Vocational Nursing Practice Act, applicable regulations, organizational policies, and established clinical supervision requirements.

The LVN may collect and organize clinical information, conduct protocol-based clinical screening, coordinate services, communicate with providers, and identify cases requiring further evaluation.

Final medical necessity determinations, adverse utilization management determinations, and independent clinical judgments outside the LVN scope of practice must be referred to appropriately qualified and authorized clinicians, including RNs and/or physicians, as required by applicable law, health plan contracts, and organizational policy.

Equal Employment Opportunity

The organization is an Equal Opportunity Employer committed to fostering an inclusive workplace. All qualified applicants will receive consideration for employment without regard to legally protected characteristics.

Minimum Qualifications, Education & Licensure

• Graduate of an accredited vocational nursing program.
• Current, active, and unrestricted California Licensed Vocational Nurse (LVN) license.
• Current BLS certification preferred.

Required Experience

• Minimum of 3 years of clinical nursing experience.
• Minimum of 1–2 years of experience in utilization management, inpatient case management, concurrent review, or managed care.
• Experience working with Medicare Advantage, managed care organizations, IPAs, medical groups, or health plans.
• Working knowledge of inpatient authorization processes, hospital levels of care, and discharge planning.
• Familiarity with utilization management guidelines, clinical review criteria, and regulatory turnaround-time requirements.
• Experience using electronic medical records, utilization management systems, and Microsoft Office applications.

Preferred Qualifications

• Prior experience performing inpatient concurrent review within an IPA, health plan, or delegated medical group.
• Experience coordinating care with acute care hospitals, skilled nursing facilities, and post-acute providers.
• Familiarity with MCG or InterQual clinical criteria.
• Knowledge of Medicare Advantage, SNP/D-SNP populations, and transitions-of-care programs.
• Experience supporting both inpatient and outpatient authorization workflows.
• Experience working in a fully remote clinical or managed care environment.
• Bilingual English/Spanish skills preferred.

Required Knowledge, Skills & Abilities

• Strong understanding of inpatient utilization management and concurrent review processes.
• Knowledge of medical terminology, common diagnoses, treatment plans, and healthcare delivery systems.
• Ability to identify clinical concerns and appropriately escalate cases requiring RN or physician review.
• Understanding of discharge planning, post-acute services, and transitions-of-care principles.
• Strong organizational skills with the ability to manage multiple cases and competing priorities.
• Excellent written and verbal communication skills.
• Ability to collaborate effectively with physicians, hospital case managers, health plans, and interdisciplinary teams.
• Strong attention to detail and commitment to accurate clinical documentation.
• Ability to work independently, prioritize assignments, and meet deadlines in a remote environment.
• Proficiency with electronic clinical systems, Microsoft Teams, Outlook, Excel, and other communication platforms.
• Flexibility to support changing operational priorities and provide cross-coverage across utilization management functions.