Lead Utilization Review - RN

We’re Personify Health. We’re the first and only personalized health platform company to bring health, wellbeing, and navigation solutions together. Helping businesses 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.

Provide daily direction and communication to utilization review staff through motivating, coaching, counseling, training and problem-solving.

Supervises all LVN and RN work and gives direction as needed. Provides supervision first level review for all outpatient and ancillary pre-certification requests for medical appropriateness using established guidelines. Provide first level review for all inpatient hospital stay including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity. Assist in audit preparation and provides training as needed on a variety of topics. Works with hospital staff to prepare for inpatient discharge planning needs to ensure a smooth transition to the next level of care. Plan, organize and distribute work; keep team informed of updates and changes in policy or procedure; instruct employees regarding procedures and methods; resolve difficult or non-routine situations or problems. Process appeals for non-certification of services; complete non-certification letter. Review plan document for benefit determinations; refer requests that fall outside the guidelines to advance review or senior care consultants. Use appropriate judgment in upward communication regarding department or employee concerns Serves as resource to other members of the UR team.