[Hiring] Utilization Review Nurse @Personify Health

Role Description

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.

• Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness.
• Review all inpatient hospital stays including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity.
• Conduct 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.
• Assist with department operations and implementations.

Qualifications

• 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 Microsoft Word, Microsoft Excel, Microsoft PowerPoint, and Outlook.
• Excellent verbal and written communication skills.
• Ability to convey complex or technical information clearly and understand complex information from others.

Requirements

• 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.