UM Nurse (LVN)

Review and triage service requests for medical necessity and timeliness, applying clinical guidelines and benefit plans to develop recommendations. Present cases to the Medical Director when further clinical review is warranted and communicate outcomes with providers and members in accordance with regulations. Ensure accurate documentation in internal systems per departmental policies and refer members to California Childrens Services, Tri-Counties Regional Center, or other care coordination programs. Identify and escalate quality-of-care concerns while participating in cross-functional meetings and emergency response programs as assigned. Candidates must hold an active, unrestricted California LVN license and knowledge of UM criteria including MCG, InterQual, Medi-Cal, and Medicare.