Utilization Review Nurse I LVN/LPN

Personify Health•Remote,

4d•$25 - $30•Remote

About The Position

Behind every prior authorization and inpatient stay is a member waiting on a decision, and you’re the one who makes sure that decision is timely, accurate, and grounded in evidence. As a Level I Utilization Management Nurse, you review requests for medical necessity, level of care, and benefit coverage, then apply clinical guidelines and plan policies to keep care appropriate and compliant. Your sharp review work protects members from delays and unnecessary services, supports providers who need clear answers, and keeps our programs ready for URAC and NCQA scrutiny. When your reviews are thorough, well-documented, and delivered on time, our whole organization earns the trust of the members and sponsors who rely on us.

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
Working knowledge of clinical guidelines such as MCG and NCCN, and UM documentation systems
Proficiency with Microsoft Word, Excel, Outlook, and Teams, with the 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 (e.g., VPN) and departmental platforms (e.g., SharePoint/Drives) in line with security policies

Nice To Haves

Prior utilization review or utilization management experience preferred

Responsibilities

Perform clinical reviews that drive sound determinations: Evaluate requests for medical necessity, appropriate level of care, documentation completeness, and benefit coverage, so members get timely decisions that meet compliance standards.
Deliver first-level review across care settings: Review outpatient and ancillary pre-certification and prior authorization requests, inpatient stays (including behavioral health, substance use, skilled nursing, and rehabilitation), and post-service or post-claim reviews as assigned.
Apply guidelines in the right hierarchy: Use internal medical policies, group-specific policies, NCCN, and MCG as applicable, and record your criteria and policy rationale in the UM system so every decision stands on solid ground.
Escalate the cases that need advanced eyes: Refer requests that fall outside guidelines, fail to meet criteria, or may require adverse determination to senior staff or the Medical Director, and support IRO referrals in line with policy and jurisdictional requirements.
Verify benefits and guide members in-network: Review plan documents to support benefit determinations, and redirect providers and members to PPO or in-network options when it fits plan requirements.
Build audit-ready case summaries: Prepare clear, complete documentation for Medical Director review, including adverse determination and IRO referral pathways, so every case holds up under scrutiny.
Hit productivity, quality, and turnaround targets: Meet established standards, take part in quality activities like inter-rater reliability (IRRA), and apply feedback to keep us audit-ready for URAC, NCQA, and other applicable standards.
Protect member privacy at every step: Follow HIPAA and minimum-necessary standards, and complete required annual training and testing on time.
Cross-train and cover where the team needs you: Step in to support team operations and service-level commitments, and contribute to staff training as appropriate.