Utilization Review Nurse, RN – Part-Time

🔥 30 minutes ago

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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 utilization management medical-necessity reviews and level-of-care determinations for requested services • Apply benefit language, plan documents, medical policies, evidence-based criteria such as MCG and NCCN, and state/federal requirements • Route requests that do not meet criteria to the Medical Director for secondary clinical review • Analyze clinical documentation for completeness and identify risk, acuity indicators, inconsistencies, or missing information • Initiate timely outreach and escalation according to utilization-management workflow • Prioritize workload based on urgency, regulatory/accreditation time frames, and member impact • Assist with in-network and benefit-compliant redirection by confirming eligibility, benefits, authorization requirements, and network status • Support appeals by preparing clinical summaries and documentation and coordinating peer-to-peer/Medical Director discussions • Document reviews, rationale, criteria or policy citations, communications, and outcomes in designated utilization-management systems • Meet productivity, quality, accuracy, and turnaround-time standards • Participate in calibration and quality activities and incorporate feedback • Maintain HIPAA compliance and confidentiality • Complete required training and annual competencies • Cross-train and provide cross-coverage to support team operations and service-level commitments

🎯 Requirements

• Current, unrestricted RN license in the United States or 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, such as acute care, med-surg, ICU/ED, or another relevant setting • Prior utilization review/utilization management experience preferred • Ability to interpret medical records and apply evidence-based criteria and plan medical policies • Basic computer literacy upon hire • Ability to work on multiple screens and proficient typing skills • Proficiency with Microsoft Word, Microsoft Excel, Outlook, and similar software applications • Excellent verbal and written communication skills • Ability to communicate complex or technical information clearly and understand complex information from others • Ability to work independently and use written resources to solve problems • Knowledge of medical claims and ICD-10, CPT, and HCPCS coding • Ability to perform essential job functions safely and successfully, with or without reasonable accommodation • Ability to maintain regular, punctual attendance • Ability to sit for 6–8 hours • Constant computer keyboard and mouse use with repetitive use of both hands • Occasional to frequent twisting of the neck and occasional bending of the neck and waist • Weekends required • Up to 28 hours per week

🏖️ Benefits

• Competitive base salary and benefits effective day one • Comprehensive medical and dental through our own health solutions • Paid Time Off • Mental health support • Retirement planning • Financial protection • Professional development with clear career progression and learning budgets • Mission-driven culture where diverse perspectives drive real impact • Wellness programs • Other employee perks • Full benefits package starting day one