About the role
Personify Health is hiring a remote Utilization Review Nurse to handle first-level and post-service reviews for pre-certification requests — including mental health, substance abuse, skilled nursing, and rehab stays. You'll work under RN supervision, applying clinical guidelines to keep reviews accurate and on schedule, with a standard Monday–Friday Pacific-hours schedule plus rotating Saturday coverage.
Responsibilities
- Complete first-level and post-service utilization reviews for pre-certification requests, including mental health, substance abuse, skilled nursing, and rehab stays
- Evaluate post-claim and post-service requests against established clinical guidelines
- Coordinate hospital discharge planning and transitions of care
- Process appeals for services that were not certified
- Prepare non-certification letters when a request doesn't meet guidelines
- Document every review in the utilization-management system using MCG guidelines and NCCN criteria
- Meet daily productivity and quality standards while working under RN supervision
Requirements
- Current, unrestricted LVN license (U.S. or territory)
- 1+ years of clinical nursing experience
- Working knowledge of medical claims, ICD-10, CPT, and HCPCS coding
- Proficiency with MS Office
- Familiarity with MCG guidelines and utilization-management systems
- Available Monday–Friday, 8:00 AM–5:00 PM Pacific, with rotating Saturday coverage
What we offer
- Competitive base pay and benefits effective day one
- Comprehensive medical, dental, and vision coverage
- Paid time off
- Mental health support
- Retirement planning
- Professional development opportunities