Remote Utilization Review Nurse-RN – CA & Compact

Job Overview

  • Clinical License RN
  • State(s) Compact, CA

Overview

Now is the time to join us!

 

We’re Personify Health. We’re the first and only personalized health platform company to bring health, wellbeing, and navigation solutions together. Helping businesses like yours optimize investments in their members while empowering people to meaningfully engage with their health. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future.

 

Responsibilities

In this role you will wear many hats, but your knowledge will be essential in the following:  

  • Provide professional assessment and review for the medical necessity of treatment requests and plans.
  • Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; review all inpatient hospital stay including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity.
  • Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO).
  • Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.
  • Refer requests that fall outside of established guidelines to advance review or senior care consultants.
  • Process appeals for non-certification of services; complete non-certification letters when appropriate.
  • Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers.
  • Identify and refer potential cases to case management, wellness, chronic disease and M2B programs.
  • Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality.
  • Utilize MCG guidelines, medical policies, up to date, Medscape and NCCN.
  • Ability to meet productivity, quality, and turnaround times on a daily, weekly and monthly requirements.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Qualifications

What you bring to the Personify Health team:

 

In order to represent the best of what we have to offer you come to us with a multitude of positive attributes including:

  • Current RN license to practice in California and/or compact state.
  • Associate degree or diploma (Nursing program) required; Bachelor’s degree preferred.
  • 3+ years clinical experience required.
  • 1+ year utilization review experience preferred.

You also take pride in offering the following Core Skills, Competencies, and Characteristics:

  • Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
  • Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft
  • PowerPoint and Outlook
  • Excellent verbal and written communication skills
  • Ability to speak clearly and convey complex or technical information in a manner that others can understand, as
  • well as ability to understand and interpret complex information from others.

No candidate will meet every single desired qualification. If your experience looks a little different from what we’ve identified and you think you can bring value to the role, we’d love to learn more about you!

 

Personify Health is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice.

 

We strive to cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive. Personify Health is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for all stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing.

 

In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges from $31.00 to $39.00. Note that pay may vary based on location, skills, and experience. This position is eligible for health, dental, vision, mental health and other benefits.

 

 

 

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