Utilization Review Nurse- RN

Personify Health

13d•$30 - $38

About The Position

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. Ready to Make Critical Decisions That Ensure Appropriate Patient Care? We're seeking a full time skilled RN who understands that utilization review is about ensuring patients receive the right care at the right time. As our Utilization Review Nurse, you'll use clinical expertise to assess medical necessity, support appropriate care transitions, and serve as an advocate for both quality care and cost-effective treatment options while working collaboratively with medical directors and care teams. What makes this role different ✓ Clinical decision-making: Your assessments directly impact patient care and treatment authorization decisions across multiple service lines ✓ Comprehensive scope: Review outpatient/ancillary pre-certifications, inpatient stays including mental health and substance abuse, skilled nursing, rehabilitation, and post-service reviews ✓ Care coordination focus: Work with hospital staff to ensure smooth patient transitions and optimal discharge planning to appropriate next-level care ✓ Professional autonomy: Make independent clinical judgments using MCG guidelines, internal medical policies, and NCCN while collaborating with medical directors

Requirements

Current RN license in United States or U.S. territory
Associate's degree or diploma (Nursing program) required
1+ year clinical experience required
Ability to meet productivity, quality, and turnaround time requirements daily
Capability to pass external audits including URAC and NCQA
Commitment to maintaining HIPAA compliance per company policies and procedures
Ability to complete and pass all annual testing including IRRA at 90% or higher
Willingness to cross-train and provide cross-coverage as needed
Strong clinical judgment for assessing medical necessity across multiple service lines
Knowledge of MCG guidelines, internal medical policies, and clinical decision-making tools
Ability to review plan documents and attempt to redirect providers and patients to PPO providers when beneficial
Proficiency with documentation software and electronic health systems
Excellent communication skills with ability to explain complex medical information clearly
Independent judgment combined with collaborative team approach
Commitment to maintaining confidentiality and minimum requirement rules
Ability to complete all required yearly training per company's expected time period
Comfort navigating fast-paced, high-volume review environment while maintaining quality standards

Responsibilities

Assess medical necessity: Conduct professional reviews of treatment requests and plans for medical appropriateness using established clinical guidelines and evidence-based criteria.
Coordinate care transitions: Partner with hospital staff to prepare patients for discharge while ensuring smooth transitions to appropriate next-level care arrangements.
Navigate complex cases: Review outpatient pre-certifications, inpatient hospital stays including mental health and substance abuse treatments, skilled nursing, and rehabilitation requirements with clinical expertise.
Ensure appropriate referrals: Work to top of RN license while ensuring proper referral to medical director for denial authorizations through independent review organizations (IRO).
Support member wellness: Identify and refer appropriate cases to case management, wellness, chronic disease, and Nurturing Together programs while maintaining thorough documentation.
Process appeals: Handle appeals for non-certification of services and complete non-certification letters when appropriate while reviewing plan documents for benefit determinations.
Maintain compliance excellence: Meet productivity, quality, and turnaround time requirements while maintaining HIPAA compliance and passing external URAC and NCQA audits.
Utilize clinical guidelines: Apply guidelines in appropriate hierarchy including MCG guidelines, internal medical policies, group-specific policies, and NCCN for consistent decision-making.

Benefits

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
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
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
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
Competitive base salary that rewards your success
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