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Personify Health Logo Personify Health · Nursing

Utilization Review Nurse-LVN/LPN

United States Employment contract 25.00 - 29.00 USD / Hour · Job Posted May 05, 2026
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Job Description

Under the supervision of a registered nurse the Utilization Review Nurse will provide professional assessment and review for the medical necessity of treatment requests and plans. The standard work schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekend coverage as required.

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
  • 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

Requirements

  • Current LVN license in the United States or U.S. territory
  • 1+ years of clinical experience
  • 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
  • Must be able to remain in a stationary position 50% of the time
  • The person in this job needs to occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities
  • Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc.
  • Frequently positions self to maintain files in file cabinets
  • Frequently moves boxes or equipment weighing up to 25 pounds
  • Must communicate information and ideas so others understand
  • Must be able to exchange accurate information in these situations
  • Must be able to observe details at close range

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
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