[Hiring] Utilization Review Nurse @Personify Health

Role Description

The Utilization Review Nurse conducts first-level clinical reviews to determine the medical necessity and appropriateness of treatment requests, working under the supervision of a Registered Nurse. This role supports timely, accurate benefit determinations across outpatient, inpatient, and post-service claims while ensuring compliance with clinical guidelines and regulatory standards.

Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required.

What You'll Actually Do

• 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; and 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.

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, 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.

Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.

Compensation

This position offers a base salary range of $25-$29 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.

Our Commitment

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—because diversity is core to who we are and critical to our work in health and wellbeing.

Stay Safe

Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to [email protected] . View all legitimate openings at personifyhealth.com/careers .