Utilization Review Nurse I LVN/LPN

About the role

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

• Perform clinical reviews that drive sound determinations: Evaluate requests for medical necessity, appropriate level of care, documentation completeness, and benefit coverage, so members get timely decisions that meet compliance standards.
• Deliver first-level review across care settings: Review outpatient and ancillary pre-certification and prior authorization requests, inpatient stays (including behavioral health, substance use, skilled nursing, and rehabilitation), and post-service or post-claim reviews as assigned.
• Apply guidelines in the right hierarchy: Use internal medical policies, group-specific policies, NCCN, and MCG as applicable, and record your criteria and policy rationale in the UM system so every decision stands on solid ground.
• Escalate the cases that need advanced eyes: Refer requests that fall outside guidelines, fail to meet criteria, or may require adverse determination to senior staff or the Medical Director, and support IRO referrals in line with policy and jurisdictional requirements.
• Verify benefits and guide members in-network: Review plan documents to support benefit determinations, and redirect providers and members to PPO or in-network options when it fits plan requirements.
• Build audit-ready case summaries: Prepare clear, complete documentation for Medical Director review, including adverse determination and IRO referral pathways, so every case holds up under scrutiny.
• Hit productivity, quality, and turnaround targets: Meet established standards, take part in quality activities like inter-rater reliability (IRRA), and apply feedback to keep us audit-ready for URAC, NCQA, and other applicable standards.
• Protect member privacy at every step: Follow HIPAA and minimum-necessary standards, and complete required annual training and testing on time.
• Cross-train and cover where the team needs you: Step in to support team operations and service-level commitments, and contribute to staff training as appropriate.

Qualifications

Education & Experience

• Graduate of an accredited nursing program (LVN/LVN)
• Current, unrestricted U.S. or U.S. territory nursing license (compact license acceptable where applicable)
• Minimum 1-2 years of recent clinical experience in acute care, med-surg, ICU/ED, or another relevant setting
• Prior utilization review or utilization management experience preferred

Technical Skills

• Ability to interpret medical records and apply evidence-based criteria and plan medical policies
• Working knowledge of clinical guidelines such as MCG and NCCN, and UM documentation systems
• Proficiency with Microsoft Word, Excel, Outlook, and Teams, with the ability to learn additional tools as assigned
• Comfort working across