[Hiring] Utilization Management Nurse @Personify Health

Role Description

Ready to make the right call on care, fast, fairly, and by the book? As a Utilization Management Nurse, you’re the clinical expert who gets it right. You’ll review requests against plan language, medical policies, and evidence-based criteria, then deliver timely, compliant determinations that protect both member access and appropriate use of resources. When a case needs a deeper look, you’ll route it to the Medical Director and support appeals with clear, complete clinical summaries. Your documentation keeps us audit-ready under NCQA and URAC standards. When you deliver accurate, on-time decisions, members get the care they need and the organization earns the trust that keeps our programs strong.

Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required.

What You’ll Actually Do

• Perform medical-necessity reviews and level-of-care determinations using benefit language, plan documents, medical policies, and nationally recognized evidence-based criteria such as MCG (and NCCN as applicable), in line with state and federal requirements.
• Hold to policy every time, and when a request doesn’t meet criteria, route it promptly to the Medical Director for secondary clinical review and potential adverse determination per UM policy and accreditation standards.
• Analyze clinical records for completeness, spot risk and acuity indicators, flag inconsistencies or missing information, and start outreach or escalation right away per UM workflow.
• Organize your workload around urgency, regulatory and accreditation time frames, and potential member impact, and raise barriers early so determinations stay timely and compliant.
• Confirm eligibility, benefits, authorization requirements, and network status to support benefit-compliant redirection when it’s clinically appropriate.
• Prepare clinical summaries and supporting documentation, coordinate peer-to-peer and Medical Director discussions when indicated, and route cases on time per policy, including Independent Review Organization (IRO) processes when required.
• Record reviews, rationale, criteria and policy citations, communications, and outcomes accurately and in real time in designated UM systems to support quality oversight, reporting, and audit readiness.
• Meet productivity, quality, accuracy, and turnaround-time expectations, take part in calibration and quality activities, and put feedback to work in your daily practice.
• Maintain HIPAA compliance and confidentiality using minimum-necessary standards, and complete required training and annual competencies by their deadlines.
• Cross-train and provide cross-coverage to keep operations running and service-level commitments met.

Qualifications

• Current, unrestricted RN license in the United States or a U.S. territory (compact license acceptable where applicable)
• Graduate of an accredited nursing program (ADN or diploma required; BSN preferred)
• Minimum 1–2 years of recent clinical experience in acute care, med-surg, ICU/ED, or another relevant setting
• Prior utilization review or utilization management experience preferred
• Ability to interpret medical records and apply evidence-based criteria and plan medical policies, with appropriate escalation to the Medical Director for non-certifications
• Working knowledge of MCG, NCCN (as applicable), NCQA and URAC standards, and HIPAA requirements
• Knowledge of medical claims and ICD-10, CPT, and HCPCS coding
• Proficiency in Microsoft Word, Excel, and Outlook
• Basic computer literacy, proficient typing, and the ability to work across multiple screens
• Ability to work independently within UM systems and programs after training

Benefits

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• 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

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. Together, our team is on a mission to empower people to lead healthier lives.