Utilization Review Nurse – RN

🔥 2 hours ago

🇺🇸 United States – Remote

💵 $30 - $40 / 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

• Evaluate requested services against benefit language, medical policy, and nationally recognized criteria such as MCG and NCCN • Determine the appropriate level of care while applying state and federal requirements • Route cases that do not meet criteria to the Medical Director for secondary clinical review • Ensure adverse determinations are timely, defensible, and aligned with NCQA/URAC accreditation standards • Analyze clinical documentation for completeness and identify acuity, risk indicators, inconsistencies, and gaps • Conduct outreach or escalation when documentation issues are identified • Manage caseloads according to urgency, regulatory deadlines, and member impact • Confirm eligibility, benefits, authorization, and network status • Steer members toward in-network, benefit-compliant options when clinically appropriate • Prepare clinical summaries and documentation for appeals • Coordinate peer-to-peer discussions with physicians and route appeals, including IRO referrals • Document reviews, rationales, criteria citations, and outcomes in UM systems in real time • Meet productivity, quality, accuracy, and turnaround standards • Participate in calibration activities and apply feedback • Maintain HIPAA compliance and complete required training and annual competencies • Cross-train and provide coverage support as needed

🎯 Requirements

• 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 in 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 • Ability to work Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required • HIPAA compliance and confidentiality using minimum-necessary standards

🏖️ 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 with clear career progression and learning budgets • Mission-driven culture where diverse perspectives drive real impact • Wellness programs • Other employee perks • Full benefits package effective day one