Utilization Review Nurse Remote

utilization utilization review nurse remote health team medical spectrum shoulder utilization outpatient lpn management
March 24, 2023
Grand Rapids, Michigan
Utilization Review Nurse Outpatient. This position is responsible for appropriately adjudicating Priority Health Preservice authorizations. Requests include Home Health, Inpatient Elective, Outpatient procedure and Durable medical equipment. Reviews consist of all products and plans priority Health offers.

Essential Functions

  • Performs medical necessity reviews for the Priority Health Preservice department.
  • Preservice prior authorization reviews consist of initial reviews, retrospective reviews, oversight of scheduling peer to peers, appeal level 1 and appeal level 2 reviews. These reviews are adjudicated according to Interqual Criteria, Medicare Guidelines, Medical Policy, Plan Documents, etc.
  • Collaborates with Priority Health Medical directors when denial or appeal adjudication is appropriate.
  • Responsible for communicating with provider offices to ensure all appropriate clinical documentation is submitted.
  • Maintains compliance with HIPPA, NCQA and CMS guidelines.


  • Required Associate's Degree or equivalent LPN

  • 5 years of relevant experience A minimum of 5 years clinical experience. Required
  • 1 year of relevant experience One year previous insurance authorization experience. Preferred

  • LIC-License Practical Nursing (LPN) - STATE_MI State of Michigan Health Management required

Physical Demands

  • Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
  • Waist to Waist > 5 lbs: Seldom up to 10 lbs
  • Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
  • Waist to Overhead > 5 lbs: Seldom up to 10 lbs
  • Bilateral Carry > 5 lbs: Seldom up to 10 lbs
  • Unilateral Carry > 5 lbs: Seldom up to 10 lbs
  • Pushing Force > 5 lbs: Seldom up to 20 lbs
  • Pulling Force > 5 lbs: Seldom up to 15 lbs
  • Sitting: Frequently
  • Standing: Occasionally
  • Walking: Occasionally
  • Forward Bend - Standing: Seldom
  • Forward Bend - Sitting: Occasionally
  • Trunk Rotation - Standing: Seldom
  • Trunk Rotation - Sitting: Occasionally
  • Squat: Seldom
  • Stair Climbing: Seldom
  • Reach - Above Shoulder: Seldom
  • Reach - at Shoulder or Below: Seldom
  • Handling: Occasionally
  • Forceful Grip > 5 lbs: Seldom
  • Forceful Pinch > 2 lbs: Seldom
  • Finger/Hand Dexterity: Frequently
  • Visual Acuity
    [None = No; Seldom = Yes]: Seldom

Primary Location
SITE - Priority Health - 1231 E Beltline - Grand Rapids

Department Name
PH - Pre-Service Utilization Management

Employment Type
Full time

Day (United States of America)

Weekly Scheduled Hours

Hours of Work
8:30 a.m. - 5:00 p.m.

Days Worked
Monday - Friday

Weekend Frequency

CURRENT SPECTRUM HEALTH TEAM MEMBERS - Please apply through Find Jobs from your Workday team member account. This career site is for Non-Spectrum Health team members only.

Spectrum Health is committed to providing a safe environment for our team members, patients, visitors and community. That is why we require a drug-free workplace and various vaccinations as a requirement for employment.

Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

If you are a qualified individual with a disability, you may request assistance in completing the application process by calling 616.###.####. We are committed to granting reasonable accommodations in accordance with applicable laws.

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