Utilization Review - RN at Personify Health

, , United States -

Full Time

Start Date

Immediate

Expiry Date

18 Dec, 25

Salary

0.0

Posted On

19 Sep, 25

Experience

0 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

RN License, Clinical Experience, Medical Claims Knowledge, ICD-10 Coding, CPT Coding, HCPCS Coding, Microsoft Office Proficiency, Electronic Health Systems, MCG Guidelines Experience, Clinical Decision-Making, Communication Skills, Independent Judgment, Care Coordination, Documentation Skills, Fast-Paced Environment Navigation

Industry

Health and Human Services

Description

Overview Who We Are Ready to create a healthier world? We are ready for you! Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future. Responsibilities Ready to Make Critical Decisions That Protect Patient Care? We're seeking a skilled RN who understands that utilization review is about ensuring patients get the right care at the right time. As our Utilization Review Nurse, you'll use your clinical expertise to assess medical necessity, support appropriate care transitions, and serve as an advocate for both quality care and cost-effective treatment options. What makes this role different ✓ Clinical decision-making: Your assessments directly impact patient care and treatment authorization decisions ✓ Flexible scheduling: Weekend availability with work-life balance support to fit your lifestyle ✓ Care coordination focus: Work with hospital staff to ensure smooth patient transitions and optimal outcomes ✓ Professional autonomy: Make independent clinical judgments while collaborating with medical directors and care teams What You'll Actually Do Assess medical necessity: Conduct professional reviews of treatment requests, inpatient stays, and post-service reviews using clinical guidelines and evidence-based criteria. Coordinate care transitions: Work directly with hospital staff to prepare patients for discharge and ensure appropriate next-level care arrangements. Navigate complex cases: Review outpatient pre-certifications, mental health and substance abuse treatments, and skilled nursing requirements with clinical expertise. Ensure appropriate referrals: Identify cases requiring medical director review, process appeals for non-certified services, and redirect to preferred providers when beneficial. Support member wellness: Refer appropriate cases to case management, wellness programs, and specialized support services while maintaining thorough documentation. Qualifications What You Bring to Our Mission The clinical foundation: Current RN license in the United States or U.S. territory 1+ years of clinical experience required The technical expertise: Knowledge of medical claims, ICD-10, CPT, and HCPCS coding Proficiency with Microsoft Office applications and electronic health systems Experience with MCG guidelines, medical policies, and clinical decision-making tools The professional qualities: Excellent communication skills with ability to explain complex medical information clearly Independent judgment combined with collaborative team approach Ability to meet productivity standards while maintaining quality and documentation requirements Comfort navigating fast-paced, high-volume review environment Why You'll Love It Here We believe in total rewards that actually matter—not just competitive packages, but benefits that support how you want to live and work. Your wellbeing comes first: Comprehensive medical and dental coverage through our own health solutions (yes, we use what we build!) Mental health support and wellness programs designed by experts who get it Flexible work arrangements that fit your life, not the other way around Financial security that makes sense: Retirement planning support to help you build real wealth for the future Basic Life and AD&D Insurance plus Short-Term and Long-Term Disability protection Employee savings programs and voluntary benefits like Critical Illness and Hospital Indemnity coverage Growth without limits: Professional development opportunities and clear career progression paths Mentorship from industry leaders who want to see you succeed Learning budget to invest in skills that matter to your future A culture that energizes: People Matter: Inclusive community where every voice matters and diverse perspectives drive innovation One Team One Dream: Collaborative environment where we celebrate wins together and support each other through challenges We Deliver: Mission-driven work that creates real impact on people's health and wellbeing, with clear accountability for results Grow Forward: Continuous learning mindset with team events, recognition programs, and celebrations that make work genuinely enjoyable The practical stuff: Competitive base salary plus commission structure that rewards your success Unlimited PTO policy because rest and recharge time is non-negotiable Benefits effective day one—because you shouldn’t have to wait to be taken care of Ready to create a healthier world? We're ready for you. No candidate will meet every single desired qualification. If your experience looks a little different from what we’ve identified and you think you can bring value to the role, we’d love to learn more about you! Personify Health is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice. In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges from [x to x]. Note that compensation may vary based on location, skills, and experience. This position is eligible for [x%] target bonus/variable compensation as well as health, dental, vision, mental health and other benefits. We strive to cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive. Personify Health is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for all stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing. #WeAreHiring #PersonifyHealth #TPA #HPA #Selffunded Beware of Hiring Scams: Personify Health will never ask for payment or sensitive personal information such as social security numbers during the hiring process. All official communication will come from a verified company email address. If you receive suspicious requests or communications, please report them to talent@personifyhealth.com. All of our legitimate openings can be found on the Personify Health Career Site. Application Deadline: Open until position is filled.

Responsibilities

As a Utilization Review Nurse, you will assess medical necessity and coordinate care transitions to ensure patients receive appropriate care. You will also navigate complex cases and support member wellness through referrals to case management and specialized services.