Utilization Review Nurse-LVN/LPN

Personify Health

4d•Onsite

About The Position

Under the supervision of a registered nurse, the Utilization Review Nurse will provide professional assessment and review for the medical necessity of treatment requests and plans. The standard work schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekend coverage as required. This role involves providing first-level review for various medical requests, ensuring adherence to guidelines, processing appeals, and collaborating with healthcare staff to facilitate patient care transitions. The nurse will also be responsible for accurate documentation and identifying potential cases for specialized programs.

Requirements

Current LVN license in the United States or U.S. territory.
1+ years of clinical experience required.
Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook
Excellent verbal and written communication skills
Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.

Responsibilities

Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity; and all post claim or post service reviews.
Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO).
Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.
Refer requests that fall outside of established guidelines to advance review or senior care consultants.
Process appeals for non-certification of services; complete non-certification letters when appropriate.
Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers.
Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together program.
Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality.
Utilize MCG guidelines, medical policies, Medscape, and NCCN.
Ability to meet productivity, quality, and turnaround times daily.
Assists with department operations and implementations