Offer summary

Qualifications:

Active Kentucky license as an RN, LPN, or Social Worker is required., Experience in utilization management, case management, or medical review is preferred., Strong understanding of medical terminology and healthcare regulations is essential., Excellent communication and decision-making skills are necessary..

Key responsabilities:

Conduct utilization management reviews following departmental policies and procedures.

Review medical necessity and appropriateness of healthcare services based on clinical guidelines.

Collaborate with healthcare providers and members to ensure quality care.

Maintain thorough documentation of all UM activities and ensure compliance with regulatory standards.

Job description

Utilization Review LPN / Social Worker

Location: Remote - Must have Kentucky License

Job Type: Temp-to-Perm

Pay Rate: $36-38/hr

Job Summary

A leading managed care organization is seeking a Utilization Review LPN or Social Worker to conduct utilization management (UM) reviews, ensuring appropriate medical services are provided in accordance with department policies and procedures. The ideal candidate will have a Kentucky (KY) licensure as an RN, LPN, or Social Worker and experience in utilization management, medical review, or related fields.

Key Responsibilities

Conduct utilization management reviews using the medical management system, following departmental policies and procedures.
Review medical necessity, appropriateness, and efficiency of healthcare services based on clinical guidelines.
Collaborate with healthcare providers and members to ensure quality care and appropriate service utilization.
Communicate effectively with internal teams and external providers regarding authorization decisions.
Identify and escalate cases requiring additional medical review or intervention.
Maintain thorough and accurate documentation of all UM activities.
Ensure compliance with regulatory and accreditation standards.

Requirements

Must have an active Kentucky (KY) license as an RN, LPN, or Social Worker.
Previous experience in utilization management, case management, or medical review preferred.
Strong understanding of medical terminology, clinical guidelines, and healthcare regulations.
Excellent communication and decision-making skills.
Proficiency with electronic medical management systems and documentation.

Work Schedule

Flexible schedule between 8:00 AM – 5:30 PM EST (varied shifts available).
No strict time zone requirements—candidates in other time zones will be accommodated.

Why Join Us?

Competitive hourly pay with potential for permanent placement.
Opportunity to work remotely with a flexible schedule.
Gain experience in a growing healthcare sector with a reputable managed care organization.

If you meet the qualifications and are interested in this opportunity, apply today!

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