Utilization Review Nurse – LVN/LPN

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Personify Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2023

⚕️ Healthcare Insurance

🧘 Wellness

🤖 Artificial Intelligence

Healthcare Insurance • Wellness • Artificial Intelligence

Personify Health is the first personalized health platform company, designed to empower individuals and organizations to achieve better health outcomes through tailored solutions and services. They offer a comprehensive range of solutions including wellbeing navigation, care management, and health plan administration, catering to employers, health systems, health plans, and brokers. Their goal is to simplify healthcare experiences and enhance engagement, ultimately helping businesses optimize their investment in employee health and wellbeing.

📋 Description

• 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

🎯 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