Utilization Review Nurse LVN/LPN Job at Personify Health

Utilization Review Nurse - LVN/LPN

Under the supervision of a registered nurse the Utilization Review Nurse will pr...

Location

United States

Salary:

25.00 - 30.00 USD / Hour

Personify Health

Expiration Date

Until further notice

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 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.

Job Responsibility

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

What we offer

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

Fulltime

New

Admissions Services Specialist

Acadia Healthcare is seeking remote Admissions Services Specialists to support o...

Location

United States , Franklin

Salary:

Not provided

Acadia Healthcare

Expiration Date

Until further notice

Requirements

Bachelor's or Master's degree in Behavioral Science, Social Work, Sociology, Nursing, or a related field
in some states, RN, LVN/LPN
Knowledge of admission/referral processes, techniques, and tools
Familiarity with behavioral health issues and services
Solid understanding of financial principles and insurance reimbursement practices
Knowledge and proficiency with Salesforce.com (or other CRM application), Concur, and MS Office application
Licensure, as required for the area of clinical specialty, i.e., RN license, CAC or other clinical counseling or therapy license, as designated by the state in which the facility operates

Job Responsibility

Manage Referral Management Portals
Monitor all faxed referrals
Monitor all webforms and call center handoffs/rollover referrals
Utilize facility admissions/exclusionary criteria to process incoming types of referrals
Respond to inquiries about the facility within facility policy timeframes
Document calls inside of Salesforce and follow-up as needed
Complete Prior Authorization
Pre-Admit the patients in billing system
Coordinate with local admissions department regarding bed availability
Facilitate intake, admissions, and utilization review process for incoming patients

Fulltime

Licensed Vocational Nurse Care Coordinator - Population Health Admin

Provides care under the direct supervision of the Population Health Director of ...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

Vocational/technical school graduate
Basic LVN Nursing skills
Knowledge of lab procedures and diagnostic testing
Ability to write clear documentation and ability to write detailed specifications
Solid organizational skills including attention to detail and multi-tasking skills
Basic computer skills
EMR Experience
3 years clinical experience with at least 2 years in a primary care clinic preferred
LVN/LPN License in the state of TX or where positions is located within the enterprise
BLS Certification if applicable

Job Responsibility

Manages a case load of 10,000-15,000 patients with identified gaps in care in collaboration with the Health Care Team
Works in collaboration with the PCMH Team in the design implementation and evaluation of the PMH model as applicable
Works proactively to coordinate preventative/follow-up care for all patients receiving care from participating providers
Reviews patient medical record to identify care gaps
Schedules needed preventative services using evidenced based Physician approved protocols and documents the encounter
Fosters a Team approach by working collaboratively with the member family PCP and other members of the healthcare team to ensure coordination of services
Assists Nurse Navigators’ in performing transition of care outreach to discharged patients to schedule return visit with the PCP per guidelines
Employs knowledge of evidenced based guidelines to effectively communicate the importance of recommended procedures and testing
Facilitates a collaborative approach with care team for identification of and closure of care gaps
Utilizes educational and behavioral change strategies to promote patient collaboration with the care team

Fulltime

Review Case Manager – IRO/UR

We are seeking a detail-oriented Review Case Manager to process Independent Revi...

Location

United States , Southfield

Salary:

Not provided

RediMinds

Expiration Date

Until further notice

Requirements

Bachelor’s degree in healthcare administration, nursing, public health, or a related field or equivalent combination of education and relevant work experience
Clinical licensure (e.g., RN, LVN/LPN, or similar) preferred but not required
Strong analytical and critical thinking skills, particularly in reviewing clinical determinations
Excellent written communication skills with a high level of clarity and professionalism
Exceptional attention to detail and organizational skills
Ability to manage multiple cases and deadlines in a remote work environment
Familiarity with utilization review, appeals processes, and IRO workflows
Working knowledge of healthcare regulations and compliance standards
Background in healthcare appeals, utilization review, case management, or related expertise
Experience working with Independent Review Organizations (IROs) preferred

Job Responsibility

Manage the full lifecycle of IRO and UR cases, from intake through final determination and closure
Review clinician determinations for accuracy, completeness, and alignment with clinical guidelines and regulatory requirements
Ensure all case documentation meets quality, audit, and compliance standards
Collaborate with clinicians, case managers, and regulatory clients to obtain and clarify required information
Identify and resolve discrepancies or gaps in clinical reviews and supporting documentation
Draft clear, concise, and well-structured decision letters, summaries, and case notes
Meet strict turnaround times and regulatory deadlines
Maintain accurate case tracking and documentation in internal systems
Contribute to quality assurance efforts and process improvement initiatives

Parttime

Licensed Nurse Care Coordinator - Population Health

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

High school diploma required
Minimum of 3 years of clinical or home health experience required
LVN/LPN in the state of employment and/or compact licensure required
Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives preferred
Knowledge of physician office practice operations and one year of experience in physician practice is preferred
Proficiency in keyboarding and EHR systems, primarily Epic

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Identify quality gaps. Participate in Quality Improvement Programs as indicated
Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments. Maintain ongoing communication with healthcare providers through various tools and meetings
Value-based care quality performance and pulls reports to identify open care gaps. Conducts telephonic outreach on behalf of providers to close care gaps & address medication adherence to facilitate star rating and quality performance
Providing counseling and health education to patients and families, using appropriate materials and standardized protocols. Serve as a subject matter expert in care transitions & quality metrics. Assist in educating practice staff on quality, payor, and government program requirements
Communicate resources and services available to patients through the continuum of care
Escalate health concerns to Primary Care providers and place referrals to appropriate care team members, i.e., Nurse Navigation, CHW, etc. Develop professional working relationships with ACO and CIN network providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness
Document relevant, comprehensive information and data using standard assessment tools. Maintain patient chart compliance through proper documentation and updated: preventative screenings, medical history, medication, and immunizations
Unburden primary care providers by placing approved orders for labs and other screenings as per the Standing Delegated orders
Perform Transition of Care calls on patients transitioning from an inpatient stay to home, or emergency department encounter to identify the need for a follow-up appointment, community resource needs, scheduling follow-up appointments, reviewing discharge instructions, and medications. Utilizing clinical judgment and problem-solving skills to coordinate appropriate care with physicians and Nurse Navigation

Fulltime

Licensed Nurse Care Coordinator - Population Health

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

High school diploma required
Minimum of 3 years of clinical or home health experience required
Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives preferred
Knowledge of physician office practice operations and one year of experience in physician practice is preferred
Proficiency in keyboarding and EHR systems, primarily Epic
LVN/LPN in the state of employment and/or compact licensure required

Job Responsibility

Identify quality gaps. Participate in Quality Improvement Programs as indicated
Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments. Maintain ongoing communication with healthcare providers through various tools and meetings
Value-based care quality performance and pulls reports to identify open care gaps. Conducts telephonic outreach on behalf of providers to close care gaps & address medication adherence to facilitate star rating and quality performance
Providing counseling and health education to patients and families, using appropriate materials and standardized protocols. Serve as a subject matter expert in care transitions & quality metrics. Assist in educating practice staff on quality, payor, and government program requirements
Communicate resources and services available to patients through the continuum of care
Escalate health concerns to Primary Care providers and place referrals to appropriate care team members, i.e., Nurse Navigation, CHW, etc. Develop professional working relationships with ACO and CIN network providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness
Document relevant, comprehensive information and data using standard assessment tools. Maintain patient chart compliance through proper documentation and updated: preventative screenings, medical history, medication, and immunizations
Unburden primary care providers by placing approved orders for labs and other screenings as per the Standing Delegated orders
Perform Transition of Care calls on patients transitioning from an inpatient stay to home, or emergency department encounter to identify the need for a follow-up appointment, community resource needs, scheduling follow-up appointments, reviewing discharge instructions, and medications. Utilizing clinical judgment and problem-solving skills to coordinate appropriate care with physicians and Nurse Navigation
Must have exceptional oral communication skills, strong organizational skills, and ability to adapt to change

Fulltime

Licensed Nurse Care Coordinator - Population Health Admin

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

High school diploma required
Minimum of 3 years of clinical or home health experience required
Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives preferred
Knowledge of physician office practice operations and one year of experience in physician practice is preferred
Proficiency in keyboarding and EHR systems, primarily Epic
LVN/LPN in the state of employment and/or compact licensure required

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Identify quality gaps. Participate in Quality Improvement Programs as indicated
Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments. Maintain ongoing communication with healthcare providers through various tools and meetings
Value-based care quality performance and pulls reports to identify open care gaps. Conducts telephonic outreach on behalf of providers to close care gaps & address medication adherence to facilitate star rating and quality performance
Providing counseling and health education to patients and families, using appropriate materials and standardized protocols. Serve as a subject matter expert in care transitions & quality metrics. Assist in educating practice staff on quality, payor, and government program requirements
Communicate resources and services available to patients through the continuum of care
Escalate health concerns to Primary Care providers and place referrals to appropriate care team members, i.e., Nurse Navigation, CHW, etc. Develop professional working relationships with ACO and CIN network providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness
Document relevant, comprehensive information and data using standard assessment tools. Maintain patient chart compliance through proper documentation and updated: preventative screenings, medical history, medication, and immunizations
Unburden primary care providers by placing approved orders for labs and other screenings as per the Standing Delegated orders
Perform Transition of Care calls on patients transitioning from an inpatient stay to home, or emergency department encounter to identify the need for a follow-up appointment, community resource needs, scheduling follow-up appointments, reviewing discharge instructions, and medications. Utilizing clinical judgment and problem-solving skills to coordinate appropriate care with physicians and Nurse Navigation

Fulltime

Licensed Nurse Care Coordinator - Population Health

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

High school diploma required
Minimum of 3 years of clinical or home health experience required
Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives preferred
Knowledge of physician office practice operations and one year of experience in physician practice is preferred
Proficiency in keyboarding and EHR systems, primarily Epic
LVN/LPN in the state of employment and/or compact licensure required

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Identify quality gaps. Participate in Quality Improvement Programs as indicated
Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments. Maintain ongoing communication with healthcare providers through various tools and meetings
Value-based care quality performance and pulls reports to identify open care gaps. Conducts telephonic outreach on behalf of providers to close care gaps & address medication adherence to facilitate star rating and quality performance
Providing counseling and health education to patients and families, using appropriate materials and standardized protocols. Serve as a subject matter expert in care transitions & quality metrics. Assist in educating practice staff on quality, payor, and government program requirements
Communicate resources and services available to patients through the continuum of care
Escalate health concerns to Primary Care providers and place referrals to appropriate care team members, i.e., Nurse Navigation, CHW, etc. Develop professional working relationships with ACO and CIN network providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness
Document relevant, comprehensive information and data using standard assessment tools. Maintain patient chart compliance through proper documentation and updated: preventative screenings, medical history, medication, and immunizations
Unburden primary care providers by placing approved orders for labs and other screenings as per the Standing Delegated orders
Perform Transition of Care calls on patients transitioning from an inpatient stay to home, or emergency department encounter to identify the need for a follow-up appointment, community resource needs, scheduling follow-up appointments, reviewing discharge instructions, and medications. Utilizing clinical judgment and problem-solving skills to coordinate appropriate care with physicians and Nurse Navigation

Fulltime

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Utilization Review Nurse LVN/LPN

Job Description

Job Responsibility

Requirements

What we offer

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