Utilization Review Nurse, RN

Overview

Personify Health is a personalized health platform company combining health, wellbeing, and navigation solutions. We are seeking a Utilization Review Nurse to join our dynamic team with weekend availability and flexible scheduling.

Responsibilities

• Provide professional assessment and review for medical necessity of treatment requests and plans under RN supervision.
• Conduct first level review for outpatient, ancillary pre-certification, inpatient hospital stays (including mental health, substance abuse, skilled nursing, rehab), and post-claim reviews.
• Ensure proper referral to medical directors for denials through independent review organizations.
• Collaborate with hospital staff for patient discharge and care transitions.
• Process appeals for non-certification and complete non-certification letters.
• Review plan documents, attempt to redirect providers and patients to PPO providers.
• Identify and refer potential cases to case management, wellness, and chronic disease programs.
• Utilize MCG guidelines, medical policies, Medscape, and NCCN while meeting productivity and turnaround times.

Qualifications

• Current RN 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 Microsoft Office applications (Word, Excel, PowerPoint, Outlook).
• Excellent verbal and written communication skills.