Role Description Provide professional assessment and review for the medical necessity of treatment requests and plans. - Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness. - Review inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity. - Conduct post claim or post service reviews. - Cross train and provide cross coverage as needed. - Work to the top of the RN license and 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 and complete non-certification letters when appropriate. - Review plan document for benefit determinations and attempt to redirect providers and patients to PPO providers. - Identify and refer potential cases to case management, wellness, chronic disease, and Nurturing Together programs. - Complete documentation for all reviews in appropriate documentation software. - Utilize guidelines in appropriate hierarchy, including MCG guidelines, internal medical policies, group specific policies, and NCCN. - Meet productivity, quality, and turnaround times daily. - Pass external audits to include URAC and NCQA. - Maintain HIPAA compliance per company’s policy and procedures. - Maintain confidentiality and minimum requirement rules. - Complete all required yearly training per company’s expected time limit. - Complete and pass all annual testing including IRRA at 90% or higher. Qualifications - Current RN license in the United States or U.S. territory. - Associate’s degree or diploma (Nursing program) required. - 1+ year clinical experience required. Requirements - Ability to perform the essential job functions safely and successfully with or without reasonable accommodation. - Ability to maintain regular, punctual attendance. - Ability to sit for 6-8 hours. - Constant use of computer keyboard and mouse; repetitive use of both hands. - Occasional to frequent twisting of neck; occasional bending of neck and at waist. - Must be able to remain in a stationary position 50% of the time. - Occasionally move about inside the office to access office machinery, filing cabinets, and meeting facilities. - Constantly operate a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc. - Frequently position self to maintain files in file cabinets. - Frequently move boxes or equipment weighing up to 25 pounds. - Must communicate information and ideas so others understand. - Must be able to observe details at close range. Benefits - Competitive base salary and benefits effective day one. - Comprehensive medical and dental through our own health solutions. - Paid Time Off—rest and recharge time is non-negotiable. - Mental health support, retirement planning, and financial protection. - Professional development with clear career progression and learning budgets. - Mission-driven culture where diverse perspectives drive real impact on people's health. Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Company Description Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive.