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Utilization Review Nurse – RN
2026-4757 Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com.
Responsibilities
Ready to turn clinical expertise into life-changing decisions, one review at a time?
Why This Role Matters
Every determination you make decides whether a member gets the care they need, when they need it. This role sits at the exact point where clinical judgment meets real-world impact, translating evidence-based criteria into decisions that protect members and keep the organization compliant, efficient, and trusted. Get it right, and members move forward with the right care in the right setting, network partners stay strong, and the organization avoids costly, avoidable risk. Get it wrong, or get it slow, and everyone feels it, from the member waiting on an answer to the Medical Director who depends on a clean, well-documented case. Your reviews are the front line of quality, and your accuracy is what turns a good UM program into a great one.
Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required.
What You'll Actually Do
- 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.
Qualifications
What You Bring to Our TeamEducation & Experience:
- 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
Technical Skills:
- 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
- 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
