Lead Utilization Review - RN

Personify Health•Remote,

54d•$38 - $44

About The Position

Personify Health is hiring an RN UM Team Lead to guide a utilization management clinical team and support timely, consistent coverage decisions. The role provides daily direction, coaches reviewers on applying medical-necessity criteria and benefit language, monitors workflow and turnaround risks, and helps maintain complete, audit-ready documentation. The team lead also develops reviewer capability, resolves barriers with cross-functional partners, protects member and company data, and promotes timely completion of required training. The schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. The position offers a base salary of $38–$44 per hour, depending on location, skills, and experience, and eligibility for the full benefits package beginning on day one.

Requirements

Active RN license.
Experience in utilization management, clinical review, or case management.
Background applying medical-necessity criteria and interpreting benefit plans in a healthcare payer or clinical review setting.
Proficiency with UM platforms and standard office/productivity tools.
Working knowledge of medical terminology and coding concepts, including ICD-10, CPT, and HCPCS, sufficient to support accurate UM documentation.
Familiarity with remote collaboration tools for team visibility and responsiveness.

Responsibilities

Set daily team priorities, reinforce expectations, and foster a culture of clinical quality and accountability.
Coach reviewers on consistent application of medical-necessity criteria, medical policy, and benefit language, and provide real-time guidance when interpretations vary.
Monitor intake volume, aging cases, and turnaround risks; raise barriers to the UM Manager with recommendations.
Review work for documentation completeness and audit readiness, and coach reviewers on clinical rationale and regulatory timeliness.
Develop reviewer capability through shadowing plans, job aids, and competency check-ins; identify training gaps and propose solutions.
Partner with providers, facilities, Case Management, Appeals, and Provider Relations to resolve barriers and keep determinations moving.
Maintain HIPAA compliance and company privacy standards, and model ethical decision-making.
Complete required training and attestations on time and keep the team on track to do the same.