Utilization Management Nurse, RN

🔥 19 hours ago

🇺🇸 United States – Remote

💵 $35 - $38 / hour

⏰ Full Time

🟢 Junior

👻 Ghost score 0%

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Personify Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2023

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Personify Health is the first personalized health platform company, designed to empower individuals and organizations to achieve better health outcomes through tailored solutions and services. They offer a comprehensive range of solutions including wellbeing navigation, care management, and health plan administration, catering to employers, health systems, health plans, and brokers. Their goal is to simplify healthcare experiences and enhance engagement, ultimately helping businesses optimize their investment in employee health and wellbeing.

📋 Description

• Perform medical-necessity reviews and level-of-care determinations using benefit language, plan documents, medical policies, and evidence-based criteria such as MCG and NCCN • Apply utilization management policies and route requests that do not meet criteria to the Medical Director for secondary clinical review • Analyze clinical records for completeness, risk and acuity indicators, inconsistencies, and missing information • Initiate outreach or escalation according to UM workflow • Prioritize workload based on urgency, regulatory and accreditation time frames, and potential member impact • Confirm eligibility, benefits, authorization requirements, and network status • Prepare clinical summaries and supporting documentation for appeals • Coordinate peer-to-peer and Medical Director discussions and route cases through IRO processes when required • Document reviews, rationale, criteria and policy citations, communications, and outcomes in UM systems • Meet productivity, quality, accuracy, and turnaround-time expectations • Participate in calibration and quality activities and apply feedback • Maintain HIPAA compliance and confidentiality • Complete required training and annual competencies • Cross-train and provide cross-coverage to maintain operations and service-level commitments • Work Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required

🎯 Requirements

• Current, unrestricted RN license in the United States or a U.S. territory; compact license acceptable where applicable • Graduate of an accredited nursing program; ADN or diploma required; BSN preferred • Minimum 1–2 years of recent clinical experience in acute care, med-surg, ICU/ED, or another relevant setting • Prior utilization review or utilization management experience preferred • Ability to interpret medical records and apply evidence-based criteria and plan medical policies • Working knowledge of MCG, NCCN as applicable, NCQA and URAC standards, and HIPAA requirements • Knowledge of medical claims and ICD-10, CPT, and HCPCS coding • Proficiency in Microsoft Word, Excel, and Outlook • Basic computer literacy and proficient typing • Ability to work across multiple screens • Ability to work independently within UM systems and programs after training

🏖️ Benefits

• Competitive base salary • Comprehensive medical and dental through our own health solutions • Paid Time Off • Mental health support • Retirement planning • Financial protection • Professional development • Clear career progression • Learning budgets • Wellness programs • Other employee perks • Full benefits package starting day one

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