Job Description

Job Description

Job Description

Position Summary

The PACE Utilization Coordinator - LVN supports utilization management functions for PACE participants. The position assists with utilization review activities, ensures accurate and timely authorizations, and supports care coordination efforts to deliver quality, cost-effective services. This role works under the supervision of the PACE Medical Director and collaborates with the clinical team and external providers.

Essential Duties and Responsibilities

• Assist in conducting concurrent and retrospective utilization management reviews.
• Support the review of hospitalizations, post-acute care stays, and specialty referrals.
• Track and process referral authorizations within required timeframes.
• Assist with discharge planning and communication with hospitals, skilled nursing facilities, and providers.
• Maintain accurate documentation of utilization management activities in the electronic medical record.
• Provide utilization data and reporting support to leadership and clinical teams.
• Identify and report potential utilization issues and outliers to the Medical Director.
• Serve as a liaison with providers and care managers for service authorization questions.
• Support the denial management and provider appeal process.
• Participate in interdisciplinary team meetings and care coordination discussions.
• Support quality improvement initiatives related to utilization management.
• Maintain current knowledge of PACE utilization requirements, policies, and procedures.
• Assist in identifying high-risk participants and escalating care concerns to medical leadership.

Minimum Qualifications

• Graduate of an accredited vocational nursing program with a current unencumbered LVN license in the State of California.
• Current BLS certification from the American Heart Association.
• Valid California driver’s license and acceptable driving record.
• Minimum two years of nursing experience with direct patient care coordination.
• Minimum one year of experience working with the frail or elderly population.
• Knowledge of State and Federal healthcare regulations, quality standards, and utilization review principles and guidelines such as Medicare, Medicaid and MCG/InterQual.
• Proficiency with Microsoft Office and electronic medical records.
• Excellent organizational and communication skills.
• Ability to interpret clinical documentation and follow established utilization guidelines.

Preferred Qualifications

• Experience with utilization management or care coordination in a PACE or senior care setting preferred.

Physical Demands and Work Environment

• Requires standing, walking, occasional pushing, pulling, and lifting.
• Ability to lift up to 30 pounds; assistance required for heavier loads.
• Manual dexterity and visual/hearing acuity required for clinical documentation and communication.
• Exposure to infectious materials and biohazards common in healthcare settings.
• Must be able to communicate with participants, caregivers, and team members, including those with cognitive or physical limitations.
• Moderate stress related to workload, deadlines, and participant needs.

Direct Reports

PACE Medical Director

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