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Clinical Review & Care Coordination Licensed Practical Nurse (LPN) SGRX

• 1.0 Grosse Pointe Park, MI Job Details Full-time $27
• $30 an hour 5 hours ago Benefits Health insurance Dental insurance 401(k) Paid time off Vision insurance Paid sick time Qualifications Customer communication Utilization review Care documentation Utilization management Clinical documentation

Licensed Practical Nurse Full Job Description Job Title :

Clinical Review & Care Coordination Licensed Practical Nurse (LPN)

Pay Rate :

$27.00

• $30.

00/hr

Location :

Grosse Pointe Park, Michigan; Hybrid with WFH option available Reports to: Sr.

Director of Medical Management & Call Center Join Our Work Family:

Experience the Difference at SGRX Health Are you ready to join a company that goes beyond just being a place of work? At SGRX Health, you're not just an employee; you're a cherished member of our caring work family. Join us in a journey where warmth meets professionalism, wrapped in innovation. Your professional growth is not only encouraged but celebrated. Our rapidly expanding, fun-loving company is more than just a workplace; it's a space where your talents are nurtured, and your well-being is our top priority. Be part of a team that values your contributions your joy. At SGRX, we're not just redefining work; we're reshaping it with heart and innovation. Come be a part of our story, where your career feels like coming home: warm, caring, and full of exciting possibilities. About the

Role :

The Clinical Review & Care Coordination nurse supports the organization's clinical management programs across Utilization Management (UM), Medication Therapy Management (MTM), and Care Coordination. The position performs structured clinical reviews, medication assessments, member outreach, care coordination, documentation, and follow-up activities within the Licensed Practical Nurse's scope of practice and established organizational protocols. The Clinical Nurse Reviewer works collaboratively with Registered Nurses, pharmacists, Medical Directors, providers, Member Services, Provider Relations, and other clinical and operational teams to promote timely access to medically appropriate care, medication safety and adherence, continuity of care, and positive member outcomes. The position serves as an important connection between members, providers, community resources and the health plan by identifying clinical needs, medication-related concerns, barriers to care, and opportunities for intervention and ensuring appropriate escalation to qualified clinical professionals when higher-level clinical judgment is required. Essential Duties and Responsibilities Utilization Management

• Perform clinical reviews of prior authorization requests using approved clinical criteria and established organizational protocols.
• Review clinical documentation for inpatient, observation, outpatient, post-acute, home health, and specialty services to determine whether established criteria are met.
• Identify requests requiring RN or Medical Director review and prepare concise clinical summaries for escalation as appropriate. Authorization Management
• Process authorization requests accurately and within established regulatory and organizational turnaround times.
• Coordinate with providers to obtain additional clinical documentation and ensure authorization information accurately reflects services, dates, units, and duration.
• Process services meeting established criteria within delegated authority and appropriately escalate requests requiring higher-level clinical review. Care Coordination
• Collaborate with Care Management, Case Management, Pharmacy, Provider Relations, providers, and other internal and external partners to support coordinated member care.
• Assist with transitions of care and coordination of medically appropriate services and follow-up needs.
• Facilitate communication among members, providers, and internal stakeholders to support continuity of care and resolution of identified needs. Medication Therapy Management
• Conduct MTM member outreach, assessments, and medication reconciliation using available pharmacy and medical claims, medication history, diagnoses, and member-reported information.
• Identify medication discrepancies, adherence and access barriers, reported side effects, and other medication-related concerns requiring follow-up or clinical evaluation.
• Provide medication education and adherence support within LPN scope of practice and escalate medication safety concerns or matters requiring higher-level clinical judgment to the appropriate clinician. Regulatory Compliance
• Perform assigned responsibilities in accordance with applicable regulatory requirements, organizational policies, clinical protocols, and LPN scope of practice.
• Maintain member confidentiality and comply with HIPAA and organizational privacy requirements.
• Support compliance with required turnaround times, quality standards, audits, and corrective action activities. Documentation
• Maintain complete, accurate, timely, and objective documentation of clinical reviews, assessments, outreach, interventions, and case activities.
• Document approvals, referrals, requests for additional information, clinical escalations, and other case dispositions according to established requirements.
• Utilize standardized documentation tools, templates, and organizational workflows. Quality Improvement
• Participate in UM, MTM, care coordination, and organizational quality improvement initiatives.
• Assist in identifying utilization trends, medication-related concerns, provider education opportunities, barriers to care, and workflow improvement opportunities.
• Support development and improvement of clinical workflows, policies, audits, and corrective action activities as assigned. Customer Service
• Provide professional clinical support to members, providers, and internal departments.
• Respond to inquiries and facilitate timely communication regarding authorization, clinical documentation, and coordination-of-care needs within assigned responsibilities.
• Promote positive member and provider relationships through timely, accurate, respectful, and service-focused communication. Preferred Skills & Qualifications Education & Licensure Graduate of an accredited Practical Nursing Program Current unrestricted Licensed Practical Nurse (LPN) license. Experience
• Minimum of two years of clinical nursing experience preferred.
• Experience in managed care, utilization management, medical claims review & auditing, medication management, care coordination, population health, telephonic nursing, or health plan operations preferred.
• Experience with medical record review, medication reconciliation, member education, facilitation of community resources and referrals and chronic or complex healthcare needs preferred.

Skills & Abilities Working knowledge of Microsoft Office software (Word, Excel, PowerPoint, CoPilot and Outlook). Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Ability to remain in a stationary position and operate a computer.

Work Environment:

This position offers flexibility to work remotely, with occasional team collaboration. While travel is rare, the role may involve attendance at meetings, conferences, or events. SGRX Health is an equal opportunity employer and welcomes applications from individuals of all backgrounds. We encourage candidates with diverse experiences and perspectives to apply.

Note:

This job description is intended to convey information essential to understanding the scope of the position and is not an exhaustive list of skills, efforts, duties, responsibilities, or working conditions associated with it. While it is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties as needed.

Pay:

$27.00

• $30.

00 per hour

Benefits:

401(k) Dental insurance Health insurance Paid sick time Paid time off Vision insurance

Work Location:

In person