Start an LVN/LPN-Led Utilization-Review Staff-Augmentation Service

1. 1

   Master the scope-of-practice split

   This model only works if you respect what an LVN or LPN can and cannot do. In many states an LVN can perform concurrent review using InterQual or MCG criteria, submit and follow up on prior authorizations, review and track medical-necessity documentation, log denials and prep initial appeals, and communicate with payers on routine requests. What requires RN or MD oversight is making independent clinical determinations, overriding payer criteria, signing complex appeals, and running peer-to-peer calls with payer medical directors. Verify the exact scope in every state you operate in.

2. 2

   Build the one-RN-plus-LVN structure

   The efficient configuration is one RN supervisor overseeing one or two LVN or LPN reviewers. The LVNs handle the 70 to 80 percent of daily workflow that does not require an RN, while the RN handles determinations, complex appeals, peer-to-peer calls, and sign-off. This is what lets you deliver utilization-review coverage at a lower blended cost than an all-RN team while staying compliant.

3. 3

   Price the savings, not the hours

   An LVN utilization-review reviewer costs a facility roughly $8 to $20 per hour less than an RN, which is $20,000 to $40,000 a year saved per position. As an independent service, LVN utilization-review consulting rates run roughly $65 to $100 per hour, with retainers of $3,000 to $6,000 per month for fractional coverage, and 90-day denial audits at $4,000 to $8,000. Position the offer around the facility's payroll savings and protected revenue, both of which dwarf your fee.

4. 4

   Prove it on a program or a backlog

   Open with a bounded engagement: take over authorization tracking and denial logging for one program, or clear a defined denial backlog. A facility running near a 18 to 22 percent denial rate that sees it move toward single digits with your team in place has the proof it needs to sign a longer contract.

5. 5

   Standardize and scale the reviewer bench

   Because LVNs are more available and lower cost than experienced UR RNs, this model scales by adding reviewers under the same RN supervision. Build criteria checklists, authorization trackers, and appeal templates so a new LVN reviewer can be productive quickly, and keep the RN focused on the high-judgment work. That leverage is what separates this from a solo consulting practice.

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Best for: LVNs, LPNs, and RN supervisors who understand utilization review and want a lower-cost, scalable service model

Not for: Anyone who would blur the LVN and RN scope-of-practice line to cut costs; the entire model depends on RN or MD oversight of determinations, complex appeals, and peer-to-peer calls, and getting that wrong is a compliance failure.