Utilization Review Nurse – LVN

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Personify Health

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1001 - 5000 Mitarbeiter

Gegründet 2023

🏥 Gesundheitswesen

💼 Beratung

📦 Logistik

Healthcare • Consulting • Logistics

Personify Health ist das erste Unternehmen für personalisierte Gesundheitsplattformen, das darauf ausgerichtet ist, Einzelpersonen und Organisationen durch maßgeschneiderte Lösungen und Dienstleistungen zu besseren Gesundheitsergebnissen zu verhelfen. Sie bieten ein umfassendes Spektrum an Lösungen wie Navigationshilfen für das Wohlbefinden, Pflegemanagement und Verwaltung von Gesundheitsplänen, die sich an Arbeitgeber, Gesundheitssysteme, Gesundheitspläne und Makler richten. Ihr Ziel ist es, das Gesundheitserlebnis zu vereinfachen und die Beteiligung zu erhöhen, um Unternehmen dabei zu helfen, ihre Investitionen in die Gesundheit und das Wohlbefinden der Mitarbeiter zu optimieren.

Beschreibung

• Own first-level reviews: Assess outpatient, ancillary, and inpatient pre-certification requests, including mental health, substance abuse, skilled nursing, and rehab stays, for medical appropriateness and necessity. • Drive post-service reviews: Evaluate post-claim and post-service requests against clinical guidelines to confirm medical necessity after the fact. • Escalate the right cases: Route denial authorizations to the Medical Director and, when required, through Independent Review Organizations (IRO), and refer out-of-guideline requests to advance review or senior care consultants. • Coordinate smooth discharges: Work directly with hospital staff to prepare patients for discharge and set up a clean transition to the next level of care. • Manage the appeals process: Process appeals for non-certified services and complete non-certification letters accurately and on time. • Redirect care in-network: Review plan documents for benefit determinations and steer providers and patients toward PPO options whenever possible. • Connect patients to the right program: Identify and refer cases to case management, wellness, chronic disease, and Nurturing Together programs when clinical needs point that way. • Document every review: Complete accurate, timely documentation in Eldorado/Episodes for every case, maintaining strict confidentiality throughout. • Apply the right criteria: Use MCG guidelines, medical policies, Medscape, and NCCN to ground every determination in evidence-based standards. • Hit the bar, every time: Meet daily productivity, quality, and turnaround-time standards, and support department operations and new initiatives as they roll out.

🎯 Anforderungen

• Current LVN license in the United States or a U.S. territory • 1+ years of clinical experience • Working knowledge of medical claims and ICD-10, CPT, and HCPCS coding • Proficiency with Microsoft Word, Excel, PowerPoint, and Outlook • Familiarity with MCG guidelines, NCCN criteria, and Medscape • Experience documenting reviews in utilization management systems (e.g., Eldorado/Episodes)

🏖️ Vorteile

• 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