Now is the time to join us! 

Who are you?

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

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

• 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.

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.

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:

• Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
• Ability to critically evaluate claims data and determine treatment plan.
• Excellent interpersonal and communication skills; strong customer orientation; good time management skills; highly organized.
• 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.
• Ability to understand and interpret complex information from others.

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

• RN Licensure required.
• Licensed in the state of California preferred
• Prior supervisory experience in utilization review, case management, or an equivalent combination of education and experience.
• 5 + years combined clinical experience required.
• > 2 years utilization review experience required

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.