Utilization Review Nurse I LVN/LPN

OverviewWho We AreBecause 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.ResponsibilitiesUtilization Management Nurse (LPN/LVN), Level IReady to make sure every member gets the right care at the right time?Why This Role MattersBehind every prior authorization and inpatient stay is a member waiting on a decision, and you’re the one who makes sure that decision is timely, accurate, and grounded in evidence. As a Level I Utilization Management Nurse, you review requests for medical necessity, level of care, and benefit coverage, then apply clinical guidelines and plan policies to keep care appropriate and compliant. Your sharp review work protects members from delays and unnecessary services, supports providers who need clear answers, and keeps our programs ready for URAC and NCQA scrutiny. When your reviews are thorough, well-documented, and delivered on time, our whole organization earns the trust of the members and sponsors who rely on us.What You’ll Actually Do 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. QualificationsWhat You Bring to Our TeamEducation & Experience: Graduate of an accredited nursing program (LVN/LPN) 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 multiple screens and a headset-based phone system, with proficient typing and accurate data entry Ability to use remote-work technology (e.g., VPN) and departmental platforms (e.g., SharePoint/Drives) in line with security policies BenefitsThe Highlights: 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 Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.Compensation: This position offers a base salary range of $25-$30 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing.Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to . View all legitimate openings at personifyhealth.com/careers.Originally posted on Himalayas