Utilization Review Nurse LVN/LPN

Personify Health

1d • Onsite

About The Position

Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. They serve employers, health plans, and health systems with data-driven solutions to reduce costs and improve health outcomes. The Utilization Review Nurse, under the supervision of a registered nurse, will provide professional assessment and review for the medical necessity of treatment requests and plans.

Requirements

• Current LVN license in the United States or U.S. territory
• 1+ years of clinical experience
• 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
• 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
• Provide first level review for all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity
• Provide first level review for 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

Benefits

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• Paid Time Off—rest and recharge time is non-negotiable
• Mental health support
• Retirement planning
• Financial protection
• Professional development with clear career progression and learning budgets
• Mission-driven culture where diverse perspectives drive real impact on people's health
• Wellness programs

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree