Virginia Premier Health Plan, Inc.

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Utilization Review LPN

Utilization Review LPN

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Job Description


Responsible for authorizing cases according to approved criteria across the continuum of care to ensure a positive patient outcome while controlling costs by performing inpatient and outpatient reviews, and identification and referral of patients appropriate for case management.


  • Obtains, reviews and enters clinical information from callers and on-site reviews according to VPHP’s policy and procedure manual for medical/behavioral health services requiring certification such as: pre-admission, admission, concurrent and retrospective review in VPHP’s computer systems.
  • Develops a complete understanding of and keeps current with customer requirements and uses knowledge as appropriate in utilization review process
  • Reviews pre-certification requests within 1 business day of receipt to determine the medical necessity and appropriateness of care using established criteria. Refers questionable cases to the Medical Director
  • Prepares and sends the appropriate certification or non-certification letter to the member, provider and hospital according to Virginia Premier Health Plan, Inc. (VPHP) policies and procedures
  • Refers potential high-risk cases which will benefit from case management services to case management
  • Interfaces with multidisciplinary staff to identify social factors impacting members’ illness and treatmen
  • Communicates effectively with customers while recognizing their various requirement and level of expertise with managed care
  • Assesses social, economic, environmental and emotional factors that interfere with patient and family adjustment to illness and treatment and collaborate with case management to develop a plan of care
  • Identifies and obtains needed community resources and provides feedback to external agencies on specified cases, as necessary
  • Assist in the coordination of the psychosocial aspects of a member’s care plan
  • Participates in VPHP’s ongoing quality improvement process 
  • Participates in continuing educational activities as appropriate
  • This position provides services and demonstrates the knowledge and ability to meet the specific needs of the following age groups:   ALL:   Infant,  Adult., Child and  Geriatric



  • Current Virginia RN Licensure or Licensed Practical Nurse with demonstrated experience in Utilization Review


  • Patient care evaluation skills and the ability to communicate well (written and verbal) with all levels of management, medical staff and employees
  • Demonstrates ability to negotiate with providers, vendors and other deliverers of services
  • PC literate with working knowledge of Microsoft Word, Excel spreadsheet programs, and various computer software programs
  • Working knowledge of resource options, and experience in making appropriate referrals
  • Possess a working knowledge of ICD10 and CPT-4 coding


  • Minimum of three years clinical experience and/or current managed care experience


  • Physical health sufficient to meet the ergonomic standards and demands of the position.


About Us

Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 


We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  


All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE


Our mission is to inspire healthy living within the communities we serve!

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