Utilization Review Nurse- LVN ( Part-time)

Overview

Who We Are

Ready to create a healthier world? We are ready for you! Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future.

 

Responsibilities

Ready to Make Critical Decisions That Ensure Appropriate Patient Care?

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. This position offers flexibility and is ideal for candidates looking for reduced hours while making an impact within the team. Evening and weekend availability will be 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.

Qualifications

What You Bring to Our Mission

The clinical foundation:

•  Current LVN license in the United States or U.S. territory.
• 1+ years of clinical experience required. 

The professional competencies:

• 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.

 

Why You'll Love It Here

We believe in total rewards that actually matter—not just competitive packages, but benefits that support how you want to live and work.

 

Your wellbeing comes first:

• Comprehensive medical and dental coverage through our own health solutions (yes, we use what we build!)
• Mental health support and wellness programs designed by experts who get it
• Flexible work arrangements that fit your life, not the other way around

 

Financial security that makes sense:

• Retirement planning support to help you build real wealth for the future
• Basic Life and AD&D Insurance plus Short-Term and Long-Term Disability protection
• Employee savings programs and voluntary benefits like Critical Illness and Hospital Indemnity coverage

 

Growth without limits:

• Professional development opportunities and clear career progression paths
• Mentorship from industry leaders who want to see you succeed
• Learning budget to invest in skills that matter to your future

 

A culture that energizes:

• People Matter: Inclusive community where every voice matters and diverse perspectives drive innovation
• One Team One Dream: Collaborative environment where we celebrate wins together and support each other through challenges
• We Deliver: Mission-driven work that creates real impact on people's health and wellbeing, with clear accountability for results
• Grow Forward: Continuous learning mindset with team events, recognition programs, and celebrations that make work genuinely enjoyable