Utilization Review Nurse (LVN)

TL;DR

Utilization Review Nurse (LVN) (Healthcare): Assessing outpatient and inpatient pre-certification requests with an accent on medical appropriateness and necessity. Focus on managing the appeals process, coordinating patient discharges, and applying evidence-based standards like MCG and NCCN.

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

Compensation: $25.00–$31.00 per hour

Company

hirify.global provides a personalized health platform integrating health plan administration, wellbeing solutions, and comprehensive care navigation.

What you will do

• Perform first-level reviews of outpatient and inpatient pre-certification requests for medical necessity.
• Evaluate post-service requests against clinical guidelines to confirm medical necessity.
• Route denial authorizations to the Medical Director or Independent Review Organizations.
• Coordinate with hospital staff to prepare patients for discharge and transition to next care levels.
• Process appeals for non-certified services and complete non-certification letters accurately.
• Document all reviews in utilization management systems like Eldorado/Episodes.

Requirements

• Current LVN license in the United States or a U.S. territory.
• 1+ years of clinical experience.
• Working knowledge of medical claims and ICD-10, CPT, and HCPCS coding.
• Familiarity with MCG guidelines, NCCN criteria, and Medscape.
• Proficiency with Microsoft Word, Excel, PowerPoint, and Outlook.

Culture & Benefits

• Full benefits package effective from day one.
• Comprehensive medical and dental coverage.
• Paid Time Off for rest and recharge.
• Mental health support, retirement planning, and financial protection.
• Professional development with learning budgets and clear career progression.