Utilization Review Nurse LVN/LPN (Healthcare)

TL;DR

Utilization Review Nurse LVN/LPN (Healthcare): Performing professional assessments and medical necessity reviews for treatment requests and inpatient stays with an accent on clinical appropriateness and regulatory guidelines. Focus on processing pre-certifications, managing discharge transitions, and ensuring accurate documentation of medical necessity.

Location: Remote (Must be based in the United States)

Salary: $25–$30 per hour

Company

hirify.global is a personalized health platform that integrates health plan administration and comprehensive care navigation to improve health outcomes.

What you will do

• Perform first-level reviews for outpatient pre-certifications and inpatient medical necessity, including mental health and rehab.
• Coordinate with hospital staff to facilitate patient discharge and smooth transitions to the next level of care.
• Process appeals for non-certification of services and generate formal non-certification letters.
• Evaluate plan documents for benefit determinations and redirect providers/patients to PPO options.
• Identify and refer potential cases to case management, wellness, and chronic disease programs.
• Utilize MCG guidelines, medical policies, Medscape, and NCCN to ensure clinical accuracy.

Requirements

• Current LVN license in the United States or U.S. territory.
• 1+ years of clinical experience.
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook).
• Work schedule: Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekend coverage.

Culture & Benefits

• Comprehensive medical and dental benefits effective from day one.
• Paid Time Off (PTO) and mental health support.
• Retirement planning and financial protection.
• Professional development with clear career progression and learning budgets.
• Inclusive, mission-driven culture that values diversity and innovation.