Utilization Review Nurse I LVN/LPN

Personify Health•Remote,

29d•$25 - $30

About The Position

Personify Health is hiring a Level I Utilization Management Nurse to review healthcare requests and support timely, accurate, evidence-based decisions. The role evaluates medical necessity, level of care, documentation completeness, and benefit coverage, applying clinical guidelines and plan policies to help ensure appropriate, compliant care. The nurse performs first-level reviews across outpatient and ancillary pre-certification and prior authorization requests, inpatient stays—including behavioral health, substance use, skilled nursing, and rehabilitation—and assigned post-service or post-claim reviews. Reviews use internal and group-specific medical policies, NCCN, and MCG as applicable. Cases that fall outside guidelines, do not meet criteria, or may require an adverse determination are escalated to senior staff or the Medical Director. The role also supports IRO referrals, benefit determinations, provider and member redirection to in-network options, and audit-ready case summaries. The position is scheduled Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. The nurse is expected to meet productivity, quality, and turnaround targets; participate in quality activities; protect member privacy under HIPAA and minimum-necessary standards; complete required annual training; and cross-train or support team operations as needed. The position offers a base salary of $25–$30 per hour, depending on location, skills, and experience, and benefits beginning on day one.

Requirements

Graduate of an accredited nursing program (LVN/LPN).
Current, unrestricted U.S. or U.S. territory nursing license; compact license acceptable where applicable.
Minimum 1–2 years of recent clinical experience in acute care, med-surg, ICU/ED, or another relevant setting.
Ability to interpret medical records and apply evidence-based criteria and plan medical policies.
Proficiency with Microsoft Word, Excel, Outlook, and Teams, and ability to learn additional tools as assigned.
Comfort working across multiple screens and a headset-based phone system, with proficient typing and accurate data entry.
Ability to use remote-work technology such as VPN and departmental platforms such as SharePoint/Drives in accordance with security policies.

Nice To Haves

Prior utilization review or utilization management experience.
Working knowledge of clinical guidelines such as MCG and NCCN, and UM documentation systems.

Responsibilities

Evaluate requests for medical necessity, appropriate level of care, documentation completeness, and benefit coverage.
Review outpatient and ancillary pre-certification and prior authorization requests, inpatient stays, and assigned post-service or post-claim reviews.
Apply internal medical policies, group-specific policies, NCCN, and MCG as applicable, and document criteria and policy rationale in the UM system.
Refer requests that fall outside guidelines, fail to meet criteria, or may require an adverse determination to senior staff or the Medical Director.
Support IRO referrals in accordance with policy and jurisdictional requirements.
Review plan documents to support benefit determinations and redirect providers and members to PPO or in-network options when plan requirements allow.
Prepare clear, complete case documentation for Medical Director review, including adverse determination and IRO referral pathways.
Meet productivity, quality, and turnaround standards; participate in quality activities such as inter-rater reliability (IRRA); and apply feedback.
Follow HIPAA and minimum-necessary standards and complete required annual training and testing on time.
Cross-train, support team operations and service-level commitments, and contribute to staff training as appropriate.