Utilization Review Nurse - LVN

Personify Health•Remote,

6d•$25 - $31•Remote

About The Position

This role is where clinical assessment meets real consequence, making sure treatment requests get matched to the right level of care, the right setting, and the right guidelines every single time. Get it right, and patients move through the system smoothly, providers stay aligned with plan benefits, and the organization avoids unnecessary cost and risk. Get it wrong, or get it slow, and care gets delayed or denied when it shouldn't be. Your accuracy and pace are what keep the entire utilization review process trustworthy.

Requirements

Current LVN license in the United States or a U.S. territory
1+ years of clinical experience
Working knowledge of medical claims and ICD-10, CPT, and HCPCS coding
Proficiency with Microsoft Word, Excel, PowerPoint, and Outlook
Familiarity with MCG guidelines, NCCN criteria, and Medscape
Experience documenting reviews in utilization management systems (e.g., Eldorado/Episodes)

Responsibilities

Assess outpatient, ancillary, and inpatient pre-certification requests, including mental health, substance abuse, skilled nursing, and rehab stays, for medical appropriateness and necessity.
Evaluate post-claim and post-service requests against clinical guidelines to confirm medical necessity after the fact.
Route denial authorizations to the Medical Director and, when required, through Independent Review Organizations (IRO), and refer out-of-guideline requests to advance review or senior care consultants.
Work directly with hospital staff to prepare patients for discharge and set up a clean transition to the next level of care.
Process appeals for non-certified services and complete non-certification letters accurately and on time.
Review plan documents for benefit determinations and steer providers and patients toward PPO options whenever possible.
Identify and refer cases to case management, wellness, chronic disease, and Nurturing Together programs when clinical needs point that way.
Complete accurate, timely documentation in Eldorado/Episodes for every case, maintaining strict confidentiality throughout.
Use MCG guidelines, medical policies, Medscape, and NCCN to ground every determination in evidence-based standards.
Meet daily productivity, quality, and turnaround-time standards, and support department operations and new initiatives as they roll out.