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Part-Time Utilization Review Nurse - RN ID-14163

Now is the time to join us! 

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.

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Responsibilities

Who are you?

We are seeking a Utilization Review Nurse to join our dynamic team on a part-time basis working up to 20 hours per week. This role requires weekend availability, and flexible scheduling to support a healthy work-life balance.

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

  • Under the supervision of a registered nurse (RN), provide professional assessment and review for the medical necessity of treatment requests and plans.

  • Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity; and all post claim or post service reviews.

  • Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO).

  • Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.

  • Refer requests that fall outside of established guidelines to advance review or senior care consultants.

 

  • Process appeals for non-certification of services; complete non-certification letters when appropriate.

  • Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers.

  • Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together program.

  • Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality.

  • Utilize MCG guidelines, medical policies, Medscape, and NCCN.

  • Ability to meet productivity, quality, and turnaround times daily.

 

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.

Qualifications

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:

  • Current RN license in the United States or U.S. territory.
  • 1+ years of clinical experience required.

 

 

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

  • Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
  • 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, as well as ability to understand and interpret complex information from others.
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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

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