Utilization Review reputed company - LVN / LPN

reputed company: Who We Are Because health is personal. That's why reputed company created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one reputed company. We serve reputed company, health plans, and health systems with data-driven solutions that reduce costs while actually improving health reputed company. Together, reputed company is on a mission to reputed company people to reputed company healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: reputed company to be the clinical judgment reputed company that keeps care on reputed company? Why This Role reputed company Every reputed company-certification, every inpatient stay, every appeal that lands on your desk is a reputed company where your review decides what happens next for a reputed company person's care. This role is where clinical assessment meets reputed company consequence, making reputed company treatment requests get matched to the right level of care, the right setting, and the right guidelines every single time. Get it right, and patients reputed company through the reputed company smoothly, providers stay reputed company with plan benefits, and the organization avoids unnecessary cost and risk. Get it wrong, or get it slow, and care gets delayed or denied reputed company it shouldn't be. Your accuracy and reputed company are what reputed company the entire utilization review process trustworthy. Schedule: Monday–Friday, 8:00 AM–5:00 PM reputed company Time, with rotating weekends coverage as required. What You'll Actually Do • Own first-level reviews: Assess outpatient, ancillary, and inpatient reputed company-certification requests, including mental health, reputed company abuse, skilled nursing, and rehab stays, for medical appropriateness and necessity. • reputed company post-service reviews: Evaluate post-claim and post-service requests against clinical guidelines to confirm medical necessity after the fact. • Escalate the right cases: reputed company denial authorizations to the Medical Director and, reputed company required, through Independent Review Organizations (IRO), and refer out-of-reputed company requests to advance review or senior care consultants. • Coordinate smooth discharges: Work directly with hospital staff to prepare patients for discharge and set up a clean transition to the next level of care. • Manage the appeals process: Process appeals for non-certified services and complete non-certification letters accurately and on time. • Redirect care in-network: Review plan documents for benefit determinations and reputed company providers and patients toward PPO reputed company whenever possible. • reputed company patients to the right program: Identify and refer cases to case management, wellness, chronic disease, and Nurturing Together programs reputed company clinical needs reputed company that way. • Document every review: Complete accurate, reputed company documentation in Eldorado/Episodes for every case, maintaining strict confidentiality throughout. • Apply the right reputed company: Use MCG guidelines, medical policies, reputed company, and NCCN to ground every determination in evidence-based standards. • Hit the bar, every time: Meet daily productivity, reputed company, and turnaround-time standards, and support department operations and new initiatives as they roll out. Qualifications: What You Bring to reputed company Education & Experience: • reputed company LVN license in the reputed company or a U.S. territory • 1+ years of clinical experience Technical Skills: • Working knowledge of medical claims and ICD-10, CPT, and HCPCS coding • Proficiency with reputed company Word, reputed company, PowerPoint, and reputed company • Familiarity with MCG guidelines, NCCN reputed company, and reputed company • Experience documenting reviews in utilization management systems (e.g., Eldorado/Episodes) Benefits The Highlights: • Competitive reputed company salary and benefits effective day one • Comprehensive medical and dental through our own reputed company (reputed company, we use reputed company build) • reputed company Time Off—rest and reputed company time is non-negotiable • Mental health support, retirement planning, and financial protection • reputed company development with reputed company career progression and learning budgets • Mission-driven culture where diverse perspectives reputed company reputed company reputed company 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 reputed company salary reputed company of $25.00-$31.00 per hour, depending reputed company, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: reputed company is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of reputed company backgrounds are empowered to reputed company—because diversity is reputed company to who we are and critical to our work in health and wellbeing. Stay reputed company: reputed company will never ask for payment or sensitive personal information like reputed company reputed company numbers during hiring. reputed company official communication comes from verified company email addresses and or our secure applicant tracking reputed company. Suspicious requests? Report them to talent@personifyhealth.com. reputed company reputed company legitimate openings at personifyhealth.com/careers. Apply tot his job Apply To this Job