Conduct first-level clinical reviews to determine the medical necessity and appropriateness of treatment requests for outpatient and inpatient services. Coordinate with hospital staff for patient discharges and process appeals for non-certification of services.
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Utilization Review Nurse (LVN) The Utilization Review Nurse conducts first-level clinical reviews to determine the medical necessity and appropriateness of treatment requests, working under the supervision of a Registered Nurse. This role supports timely, accurate benefit determinations across outpatient, inpatient, and post-service claims while ensuring compliance with clinical guidelines and regulatory standards.
Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as 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. Assists with department operations and implementations
What You Bring to Our Team Education and Experience: Current LVN license in the United States or U.S. territory. 1+ years of clinical experience required. Required Knowledge, Skills, and Abilities: 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.
This job description is not intended to contain a comprehensive list of activities, duties, or responsibilities, but constitutes a general description of the scope and function of the role within the company. Activities, duties, and responsibilities are subject to change at any time with or without notice.
The Highlights: 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 Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.
This position offers a base salary range of $25-$29 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.
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Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing.
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Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com. View all legitimate openings at personifyhealth.com/careers.
Requires a current LVN license in the United States and at least one year of clinical experience. Candidates must be proficient in medical coding (ICD-10, CPT, HCPCS) and Microsoft Office applications.