[Hiring] Utilization Review Nurse I LVN/LPN @Personify Health

Role Description

Ready to make sure every member gets the right care at the right time?

As a Level I Utilization Management Nurse, you review requests for medical necessity, level of care, and benefit coverage, then apply clinical guidelines and plan policies to keep care appropriate and compliant. Your sharp review work protects members from delays and unnecessary services, supports providers who need clear answers, and keeps our programs ready for URAC and NCQA scrutiny.

When your reviews are thorough, well-documented, and delivered on time, our whole organization earns the trust of the members and sponsors who rely on us.

What You’ll Actually Do

• Perform clinical reviews that drive sound determinations:
• Evaluate requests for medical necessity, appropriate level of care, documentation completeness, and benefit coverage.
• Deliver first-level review across care settings:
• Review outpatient and ancillary pre-certification and prior authorization requests, inpatient stays, and post-service or post-claim reviews as assigned.
• Apply guidelines in the right hierarchy:
• Use internal medical policies, group-specific policies, NCCN, and MCG as applicable.
• Escalate the cases that need advanced eyes:
• Refer requests that fall outside guidelines or may require adverse determination to senior staff or the Medical Director.
• Verify benefits and guide members in-network:
• Review plan documents to support benefit determinations.
• Build audit-ready case summaries:
• Prepare clear, complete documentation for Medical Director review.
• Hit productivity, quality, and turnaround targets:
• Meet established standards and take part in quality activities.
• Protect member privacy at every step:
• Follow HIPAA and minimum-necessary standards.
• Cross-train and cover where the team needs you:
• Step in to support team operations and service-level commitments.

Qualifications

• Graduate of an accredited nursing program (LVN/LPN)
• Current, unrestricted U.S. or U.S. territory nursing license (compact license acceptable where applicable)
• Minimum 1-2 years of recent clinical experience in acute care, med-surg, ICU/ED, or another relevant setting
• Prior utilization review or utilization management experience preferred
• Ability to interpret medical records and apply evidence-based criteria and plan medical policies
• Working knowledge of clinical guidelines such as MCG and NCCN, and UM documentation systems
• Proficiency with Microsoft Word, Excel, Outlook, and Teams
• Comfort working across multiple screens and a headset-based phone system
• Ability to use remote-work technology (e.g., VPN) and departmental platforms (e.g., SharePoint/Drives)

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

Company Description

Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes.