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.

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).

Clinical Review Manager – LPN

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