[Hiring] Lead Utilization Review-RN @Personify Health

Role Description

The RN Utilization Management (UM) Team Lead provides clinical and operational leadership to support timely, and evidence-based coverage determinations. This role leads day-to-day UM execution through:

• Coaching and development of clinical reviewers
• Auditing of clinical reviewers
• Quality oversight
• Case escalation support
• Partnership with internal and external stakeholders to promote appropriate level of care and smooth transitions

The Team Lead reinforces compliance with applicable regulatory, contractual, and accreditation requirements, supports audit readiness and consistency in decision-making, and contributes to continuous improvement of UM workflows and member/provider experience.

This Candidate will have to work between PST hours.

Qualifications

• Knowledge of medical claims and ICD-10, CPT, HCPCS coding
• Ability to critically evaluate claims data and determine treatment plan
• Excellent interpersonal and communication skills
• Strong customer orientation
• Good time management skills
• Highly organized
• Proficiency in software applications including Microsoft Word, Excel, PowerPoint, and Outlook
• Excellent verbal and written communication skills
• Ability to speak clearly and convey complex or technical information in an understandable manner
• Ability to understand and interpret complex information from others
• RN Licensure required
• Licensed in the state of California preferred
• Prior supervisory experience in utilization review, case management, or an equivalent combination of education and experience
• 5+ years combined clinical experience required
• 2+ years utilization review experience required

Requirements

• Serve as a visible first-line leader for assigned UM staff by setting daily priorities and reinforcing expectations
• Coach reviewers on consistent application of medical-necessity criteria, medical policy, and benefit plan language
• Monitor daily workflow health (intake volume, aging, and turnaround risks) and coordinate coverage plans
• Reinforce documentation and communication standards by reviewing work for completeness and audit readiness
• Support onboarding and skill development through shadowing plans and competency check-ins
• Partner with providers, facilities, and internal teams to resolve barriers to timely determinations
• Maintain confidentiality and comply with HIPAA and company privacy/security policies
• Complete required training and attestations within established timelines

Benefits

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions
• 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

Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.

Company Description

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.