Utilization Review Nurse: Drive Care & Treatment Decisions

Personify Health, Inc.; United States; On-site; USD 34,000 - 43,000; Full time

Benefits offered by this job

Competitive base salary

Benefits from day one

PTO and paid time off

Mental health support

Professional development

Job summary

Personify Health, Inc. is seeking a licensed LVN to perform utilization review duties. You will review pre-certifications across services, evaluate post-service requests, and coordinate discharge planning with hospital staff while ensuring adherence to guidelines.

The role requires 1+ year of clinical experience, knowledge of medical claims coding, and strong documentation within Eldorado/Episodes. Competitive benefits apply, with daily responsibilities supporting efficient patient care and cost

Qualifications

• Current LVN license in the United States or a U.S. territory.
• Minimum 1 year of clinical experience.

Responsibilities

• Own first-level reviews for outpatient, ancillary, and inpatient pre-certification requests for medical appropriateness and necessity.
• Drive post-service reviews to confirm medical necessity after the fact.
• Escalate denial authorizations to Medical Director or IRO when required.
• Coordinate discharge planning with hospital staff for smooth transition to next level of care.
• Process appeals for non-certified services and complete non-certification letters accurately and on time.

Skills

Medical claims

ICD-10/CPT/HCPCS

MS Office

MCG/NCCN/Medscape familiarity

Documentation in Eldorado/Episodes

Clinical assessment skills

Education

LVN license in United States

1+ years clinical experience

Tools

Eldorado/Episodes

Job description

Personify Health, Inc. is seeking a licensed LVN to perform utilization review duties. You will review pre-certifications across services, evaluate post-service requests, and coordinate discharge planning with hospital staff while ensuring adherence to guidelines.

The role requires 1+ year of clinical experience, knowledge of medical claims coding, and strong documentation within Eldorado/Episodes. Competitive benefits apply, with daily responsibilities supporting efficient patient care and cost