LVN Utilization Management Nurse

Care Management Irvine, California


Job Description Summary

Reporting to the Director, Managed Care the Utilization Management (UM), Licensed Vocational Nurse is responsible for facilitating pre-certification of medical services and post-service review of medical claims by accessing network partner systems. Position will communicate with vendors to obtain and process life claims for Western Growers Assurance Trust (WGAT)/Pinnacle employer groups. Collaborates with care management nurses to coordinate medically necessary care that saves the client revenue. Assists in the process of Disease/Health Management by entering participant information into the VITAL platform computer program, contacting participants by telephone, and sending out appropriate materials to educate members about their disease processes. Incumbent will help facilitate primary care and specialist provider appointments as necessary and assure patient is managed in the least costly manner without compromising quality of care and services.


  • Vocational Nurse license in the State of California required with two years of experience in health insurance preferred
  • Strong clinical assessment knowledge and health education background
  • Comprehensive understanding of generally accepted medical practice, state mandated benefits and plan language
  • Strong skills in Microsoft Office products
  • Ability to learn claims and authorization systems
  • Proficient knowledge and understanding of coding books and medical terminology
  • Comprehensive understanding of health insurance claims.
  • Previous experience in utilization review, medical review and case management activities preferred
  • Excellent oral and written communication skills; Spanish fluency preferred
  • Verifiable, clean DMV record and the ability to travel to various locations throughout the U.S. up to 30% of time.

Duties And Responsibilities

Determine Medical Necessity

  • Perform pre-certification process by obtaining, organizing, and synthesizing clinical, benefit, and network information.
  • Obtain and maintain clinical records from providers and facilities
  • Assist with development of the UM program, care management program and other claims management projects.
  • Collect the necessary information for vendor network to initiate processing of life claims. Submit complete information to vendor network.
  • Perform claims medical necessity review.
  • Maintain positive working relationship with Provider Maintenance (PM) Department and advise PM of issues with contracting, network, and rosters.
  • Determine when physician advisor involvement is appropriate on a case by case basis. Follow-up with the results of reviews sent to physician advisors.

Customer Service

  • Monitor telephone queue and intervene as appropriate to maintain standards for abandonment rate and response times.
  • Maintain appropriate turnaround times for routine, urgent, and stat authorization requests.
  • Train new Intake Coordinators and maintain current training materials.
  • Conduct Intake Coordinator meetings as determined by new procedures, staffing changes, etc.


  • Handle all initial and follow up assessments related to our participants understanding and acceptance of the current and projected future needs to best manage their disease state.
  • Establish and manage daily schedules with preference to the individual needs of clients and members. Maintain Outlook calendar for transparency and to allow support staff the ability to book member assessments and follow-up appointments.
  • Forward clinical issues to the appropriate nursing staff for review and input and follow up on plan of care and administrative issues as appropriate.
  • Enter accurate and complete updates and ongoing tracking measures into the computer system including any updates to the participant plan of care.
  • Work with Claims, Customer Service, Provider Maintenance and Contracting staff, as necessary, to provide input on any special needs or circumstances of participants.
  • Enter new Disease Management cases as identified and send participation letters to providers and members as appropriate.
  • Provide education materials by mail for the members, follow up that they were received, determine that they understand their use, and answer any questions the participants may have.
  • Perform annual satisfaction surveys with members participating in the Disease Management Programs and provide results for internal use.
  • Maintain records of patient related phone conversations in the appropriate system e.g., Vital
  • Transmit correspondence or medical records by mail, e-mail, or fax maintaining appropriate confidentiality.
  • Receive and review medical documents as appropriate and protect the security of medical records to ensure that confidentiality is maintained.
  • Compile and record medical reports or correspondence in the appropriate reporting software.


  • Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results.
  • Maintain a clean DMV record and the ability to travel to locations throughout the US (mainly California and Arizona) up to 30% of time.
  • Other duties as assigned

Physical Demands/Work Environment

The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.