Personify Health logo
Personify Health

Because health is personal

Utilization Review Nurse – LVN/LPN

GeneralGeneralFull TimeRemoteJuniorTeam 1,001-5,000Since 2023H1B No SponsorCompany SiteLinkedIn

Location

United States

Posted

21 days ago

Salary

$25 - $30 / hour

Seniority

Junior

Professional Certificate1 yr expEnglish

Job Description

Utilization Review Nurse – LVN/LPN

Personify Health

• 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 • 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

Job 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.

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, 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

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