Utilization Review Nurse - LVN / LPN

Overview Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities Ready to be the clinical judgment call that keeps care on track? Why This Role Matters Every pre-certification, every inpatient stay, every appeal that lands on your desk is a moment where your review decides what happens next for a real person's care. This role is where clinical assessment meets real consequence, making sure treatment requests get matched to the right level of care, the right setting, and the right guidelines every single time. Get it right, and patients move through the system smoothly, providers stay aligned with plan benefits, and the organization avoids unnecessary cost and risk. Get it wrong, or get it slow, and care gets delayed or denied when it shouldn't be. Your accuracy and pace are what keep the entire utilization review process trustworthy. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekends coverage as required. What You'll Actually Do 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. Qualifications What You Bring to Our Team Education & Experience: Current LVN license in the United States or a U.S. territory 1+ years of clinical experience Technical Skills: 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) Benefits 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. Compensation: This position offers a base salary range of $25.00-$31.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our 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. Stay 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 [email protected]. View all legitimate openings at personifyhealth.com/careers.