Utilization Review Nurse – LVN/LPN

🕒 June 24

🇺🇸 United States – Remote

💵 $25 - $30 / hour

⏰ Full Time

🟢 Junior

👻 Ghost score 45%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Personify Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2023

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

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

• Conduct first-level clinical reviews to determine medical necessity and appropriateness of treatment requests under the supervision of a Registered Nurse • Support timely, accurate benefit determinations across outpatient, inpatient, and post-service claims • Provide first-level review for outpatient and ancillary pre-certification requests, inpatient hospital stays, and post-claim or post-service reviews • Refer denial authorizations to the medical director through independent review organizations • Work with hospital staff to prepare patients for discharge and ensure smooth transitions to the next level of care • Refer requests outside established guidelines to advance review or senior care consultants • Process appeals for non-certification of services and complete non-certification letters • Review plan documents for benefit determinations and redirect providers and patients to PPO providers • Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together programs • Complete review documentation in Eldorado/Episodes and maintain confidentiality • Utilize MCG guidelines, medical policies, Medscape, and NCCN • Meet daily productivity, quality, and turnaround-time requirements • Assist with department operations and implementations

🎯 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 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 • Ability to understand and interpret complex information from others • Ability to work Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required

🏖️ Benefits

• Competitive base salary and benefits effective day one • Comprehensive medical and dental through our own health solutions • Paid Time Off • Mental health support • Retirement planning • Financial protection • Professional development with clear career progression and learning budgets • Wellness programs • Other employee perks