Utilization Review Nurse, RN

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Personify Health

WebsiteLinkedInAlle Stellen

1001 - 5000 Mitarbeiter

Gegründet 2023

🏥 Gesundheitswesen

💼 Beratung

📦 Logistik

Healthcare • Consulting • Logistics

Personify Health ist das erste Unternehmen für personalisierte Gesundheitsplattformen, das darauf ausgerichtet ist, Einzelpersonen und Organisationen durch maßgeschneiderte Lösungen und Dienstleistungen zu besseren Gesundheitsergebnissen zu verhelfen. Sie bieten ein umfassendes Spektrum an Lösungen wie Navigationshilfen für das Wohlbefinden, Pflegemanagement und Verwaltung von Gesundheitsplänen, die sich an Arbeitgeber, Gesundheitssysteme, Gesundheitspläne und Makler richten. Ihr Ziel ist es, das Gesundheitserlebnis zu vereinfachen und die Beteiligung zu erhöhen, um Unternehmen dabei zu helfen, ihre Investitionen in die Gesundheit und das Wohlbefinden der Mitarbeiter zu optimieren.

Beschreibung

• Conduct medical-necessity reviews: Evaluate requested services against benefit language, medical policy, and nationally recognized criteria (MCG, NCCN) to determine the appropriate level of care, applying state and federal requirements at every step. • Escalate non-certifications with precision: Route cases that don't meet criteria to the Medical Director for secondary clinical review, ensuring every adverse determination is timely, defensible, and aligned with NCQA/URAC accreditation standards. • Dig into the clinical record: Analyze documentation for completeness, flag acuity and risk indicators, catch inconsistencies or gaps, and act fast with outreach or escalation when something doesn't add up. • Prioritize with purpose: Manage a caseload by urgency, regulatory deadline, and member impact, and flag barriers early so determinations stay timely and compliant. • Redirect care in-network: Confirm eligibility, benefits, authorization, and network status to steer members toward in-network, benefit-compliant options when clinically appropriate. • Build the appeals case: Prepare clinical summaries and documentation, coordinate peer-to-peer discussions with physicians, and route appeals (including IRO referrals) accurately and on time. • Document with rigor: Capture every review, rationale, criteria citation, and outcome in UM systems in real time, creating a clean audit trail that supports quality oversight and reporting. • Hit the bar, every time: Meet productivity, quality, accuracy, and turnaround standards, participate in calibration activities, and put feedback into action immediately. • Protect what matters: Maintain HIPAA compliance and confidentiality using minimum-necessary standards, and stay current on required training and annual competencies. • Show up for the team: Cross-train and flex into coverage roles as needed, keeping operations running and service commitments met.

🎯 Anforderungen

• Current, unrestricted RN license in the United States or a U.S. territory (compact license accepted where applicable) • Graduate of an accredited nursing program (ADN or diploma required; BSN preferred) • 1-2+ years of recent clinical experience (acute care, med-surg, ICU/ED, or similar setting) • Utilization review/utilization management experience preferred • Proficiency with Microsoft Word, Excel, and Outlook • Working knowledge of ICD-10, CPT, and HCPCS coding and medical claims • Ability to interpret medical records and apply evidence-based criteria and plan medical policies • Comfort working across multiple screens and systems with strong typing proficiency • Ability to work independently within UM platforms and workflows after training

🏖️ Vorteile

• Competitive base salary and benefits effective day one • Comprehensive medical and dental through our own health solutions (yes, we use what we build) • Paid Time Off—rest and recharge time is non-negotiable • Mental health support, retirement planning, and financial protection • Professional development with clear career progression and learning budgets • Mission-driven culture where diverse perspectives drive real impact on people's health