Clinical Review Manager – LPN

Job Description: • Initiate referrals and support care coordination workflows by gathering required clinical information and confirming benefit completeness under established UM procedures. • Perform structured clinical reviews using preset criteria and templates, escalating any findings requiring RN/Medical Director interpretation. • Consult with supervising RN or Medical Director when requests involve clinical questions, exceptions, or scenarios requiring higher level clinical judgment. • Assist nonclinical staff by clarifying clinical documentation, interpreting request elements within LPN practice parameters. • Apply approved medical appropriateness criteria and contractual eligibility information to support intake validation and preparation of clinical review materials. • Document all review activities in required UM systems with accuracy, completeness, and adherence to regulatory documentation standards. • Communicate with providers, members, and internal teams regarding missing documentation, process requirements, and case status. • Participate in quality improvement, compliance activities, and competency requirements tied to UM program standards. Requirements: • Licensed Practical Nurse (LPN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law. • 1-2 years - Clinical experience required. • Knowledge of community resources, benefits, and service authorization processes. • Familiarity with care management frameworks and regulatory requirements. • High attention to detail with the ability to document accurately and meet regulatory standards (NCQA, URAC, CMS). Benefits: • Health insurance • 401(k) matching • Flexible work hours • Paid time off • Remote work options