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Utilization Review Nurse I – LVN/LPN
Personify Health. Evaluate requests for medical necessity, appropriate level of care, documentation completeness, and benefit coverage .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical necessity evaluation, utilization management, and adherence to clinical guidelines such as MCG and NCCN. Proficient in interpreting medical records and ensuring compliance with HIPAA standards while maintaining productivity and quality in case reviews.
Highest-signal resume keywords
Utilization Review ExperienceClinical Guidelines KnowledgeNursing License (LVN/LPN)Data Entry ProficiencyMicrosoft Office Suite Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Necessity EvaluationUtilization ManagementClinical Documentation ReviewEvidence-Based Criteria ApplicationCase Summary PreparationPost-Service ReviewAdverse Determination ProcessInter-Rater Reliability ActivitiesAudit ReadinessTyping Accuracy
Soft Skills
Team CollaborationAttention to DetailAdaptabilityCommunication SkillsTraining Contribution
Tools & Technologies
Utilization Management SystemsMicrosoft WordMicrosoft ExcelMicrosoft OutlookMicrosoft TeamsVPN TechnologySharePointHeadset-Based Phone System
Certifications & Qualifications
Current Nursing LicenseAnnual Training Compliance
Industry Keywords
HIPAA ComplianceNCQA StandardsURAC StandardsBehavioral HealthSubstance UseSkilled NursingRehabilitationAcute CareMed-SurgICU/ED
About the role
Key responsibilities & impact- Evaluate requests for medical necessity, appropriate level of care, documentation completeness, and benefit coverage
- Review outpatient and ancillary pre-certification and prior authorization requests
- Review inpatient stays, including behavioral health, substance use, skilled nursing, and rehabilitation
- Perform post-service or post-claim reviews as assigned
- Apply internal medical policies, group-specific policies, NCCN, and MCG guidelines
- Record criteria and policy rationale in the utilization management system
- Refer cases outside guidelines, failing criteria, or potentially requiring adverse determination to senior staff or the Medical Director
- Support IRO referrals according to policy and jurisdictional requirements
- Review plan documents to support benefit determinations
- Redirect providers and members to PPO or in-network options when appropriate
- Prepare complete case summaries for Medical Director review, including adverse determination and IRO referral pathways
- Meet productivity, quality, and turnaround targets
- Participate in quality activities such as inter-rater reliability (IRRA)
- Apply feedback to maintain audit readiness for URAC, NCQA, and other applicable standards
- Protect member privacy and follow HIPAA and minimum-necessary standards
- Support team operations and service-level commitments
- Contribute to staff training as appropriate
Requirements
What you’ll need- Graduate of an accredited nursing program (LVN/LPN)
- Current, unrestricted U.S. or U.S. territory nursing license; compact license acceptable where applicable
- Minimum 1-2 years of recent clinical experience in acute care, med-surg, ICU/ED, or another relevant setting
- Prior utilization review or utilization management experience preferred
- Ability to interpret medical records and apply evidence-based criteria and plan medical policies
- Working knowledge of MCG and NCCN clinical guidelines and UM documentation systems
- Proficiency with Microsoft Word, Excel, Outlook, and Teams
- Ability to learn additional tools as assigned
- Comfort working across multiple screens and a headset-based phone system
- Proficient typing and accurate data entry
- Ability to use remote-work technology such as VPN and departmental platforms such as SharePoint/Drives in line with security policies
- HIPAA and minimum-necessary standards compliance
- Required annual training and testing completed on time
Benefits
Comp & perks- Competitive base salary
- Benefits effective day one
- Comprehensive medical and dental coverage
- Paid Time Off
- Mental health support
- Retirement planning
- Financial protection
- Professional development
- Clear career progression
- Learning budgets
- Wellness programs
- Other employee perks
- Mission-driven culture where diverse perspectives drive real impact