Utilization Review Nurse - LVN/LPN

Overview

Who We Are Ready to create a healthier world? We are ready for you! Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future.

Responsibilities

Ready to Be the Clinical Guardian Who Ensures Members Get the Right Care at the Right Time? We're seeking a skilled LVN/LPN who understands that utilization review is about ensuring patients receive medically necessary care in the most appropriate setting. As our Utilization Review Nurse, you'll use clinical expertise to assess treatment requests while facilitating smooth care transitions and serving as an advocate for both quality care and optimal resource utilization. What makes this role different ✓ Clinical decision-making: Your nursing assessments directly impact patient care authorization decisions and treatment pathways ✓ Care coordination focus: Work with hospital staff to ensure smooth patient transitions and optimal care continuity ✓ Professional autonomy: Make independent clinical judgments using evidence-based guidelines while collaborating with medical directors ✓ Member advocacy: Identify opportunities to connect members with case management, wellness, and specialized support programs What You'll Actually Do Provide clinical assessment: Deliver professional assessment and review for medical necessity of treatment requests and care plans under RN supervision. Conduct comprehensive reviews: Perform first-level review for outpatient and ancillary pre-certification requests, inpatient hospital stays including mental health and substance abuse, and post-service reviews. Facilitate care transitions: Work directly with hospital staff to prepare patients for discharge and ensure appropriate next-level care arrangements. Navigate complex cases: Review plan documents for benefit determinations, attempt redirection to preferred providers, and refer cases outside established guidelines to advanced review. Process appeals systematically: Handle appeals for non-certification of services while completing appropriate documentation and correspondence. Connect members to resources: Identify and refer potential cases to case management, wellness, chronic disease, and specialized programs while maintaining comprehensive documentation.

Qualifications

What You Bring to Our Mission The clinical foundation:

• Current unrestricted LVN/LPN license required
• 2-3 years clinical nursing experience required
• 1 year recent experience in Utilization Review or Utilization Management at health plan or managed care organization preferred
• Authorization to work in the US

The technical expertise:

• Knowledge of medical claims, ICD-10, CPT, and HCPCS coding
• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint, Outlook)
• Experience with MCG guidelines, medical policies, Medscape, and NCCN preferred

The professional qualities:

• Excellent verbal and written communication skills with ability to convey complex medical information clearly
• Capability to understand and interpret complex information from various healthcare stakeholders
• Ability to meet productivity, quality, and turnaround time requirements while maintaining clinical accuracy
• Strong clinical judgment combined with understanding of managed care principles and cost-effective care delivery

Why You'll Love It Here We believe in total rewards that actually matter—not just competitive packages, but benefits that support how you want to live and work. Your wellbeing comes first:

• Comprehensive medical and dental coverage through our own health solutions (yes, we use what we build!)
• Mental health support and wellness programs designed by experts who get it
• Flexible work arrangements that fit your life, not the other way around

Financial security that makes sense:

• Retirement planning support to help you build real wealth for the future
• Basic Life and AD&D Insurance plus Short-Term and Long-Term Disability protection
• Employee savings programs and voluntary benefits like Critical Illness and Hospital Indemnity coverage

Growth without limits:

• Professional development opportunities and clear career progression paths
• Mentorship from industry leaders who want to see you succeed
• Learning budget to invest in skills that matter to your future

A culture that energizes:

• People Matter: Inclusive community where every voice matters and diverse perspectives drive innovation
• One Team One Dream: Collaborative environment where we celebrate wins together and support each other through challenges
• We Deliver: Mission-driven work that creates real impact on people's health and wellbeing, with clear accountability for results
• Grow Forward: Continuous learning mindset with team events, recognition programs, and celebrations that make work genuinely enjoyable

The practical stuff:

• Competitive base salary plus commission structure that rewards your success
• Unlimited PTO policy because rest and recharge time is non-negotiable
• Benefits effective day one—because you shouldn’t have to wait to be taken care of

Ready to create a healthier world? We're ready for you. No candidate will meet every single desired qualification. If your experience looks a little different from what we’ve identified and you think you can bring value to the role, we’d love to learn more about you! Personify Health is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice. In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges from $25 to $30 per hour. Note that compensation may vary based on location, skills, and experience. This position is eligible for health, dental, vision, mental health and other benefits. We strive to cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive. Personify Health is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for all stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing. #WeAreHiring #PersonifyHealth #TPA #HPA #Selffunded Beware of Hiring Scams: Personify Health will never ask for payment or sensitive personal information such as social security numbers during the hiring process. All official communication will come from a verified company email address. If you receive suspicious requests or communications, please report them to [email protected]. All of our legitimate openings can be found on the Personify Health Career Site. Application Deadline: Open until position is filled. Apply tot his job Apply To this Job