Utilization Review Nurse - RN

Personify Health•Remote,

5d•$30 - $38•Remote

About The Position

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.

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 (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

Nice To Haves

BSN preferred
Utilization review/utilization management experience

Responsibilities

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.